





\4..:3 



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gfejUNITED STATES OF AMERICA.^ 



NERVOUS DISEASES 



WITH HOMEOPATHIC TREATMENT. 



JOSEPH T. O'CONNOR, M. D., Ph. D., 

PROFESSOR OF NERVOUS DISEASES IN THE NEW YORK HOMOEOPATHIC MEDICAL COLLEGE AMI 

HOSPITAL; PROFESSOR OF MENTAL AND NERVOUS DISEASES IN THE NEW YORK MEDICAL 

COLLEGE AND HOSPITAL FOR WOMEN; NEUROLOGIST TO THE LAURA FRANKLIN 

FREE HOSPITAL FOR CHILDREN, TO THE FLOWER HOSPITAL, AND TO 

THE METROPOLITAN HOSPITAL (BLACKWELL's ISLAND); CONSULTING 

NEUROLOGIST TO THE NEW YORK OPHTHALMIC HOSPITAL ; 

MEMBER OF AMERICAN INSTITUTE OF HOMCEOPATHY, 

ETC., ETC. 



ILLUSTRATED. 



NEW YORK. 
BOERICKE, RUNYON & ERNESTY. 



1898. 







SECOND OOP*. v\ 



51663 



Copyright, 1898. 
Ey Boericke, Runyon & Ernesty. 



TO 



THE MEMORY OF THE LATE 

PROFESSOR A. R. THOMAS, M. D. 

of PHILADELPHIA, 



AT WHOSE SKILLED HANDS I RECEIVED MY FIRST KNOWLEDGE OF THE 
BENEFICENT POWER OF HOMOZOPATHV 



I 

THESE PAGES ARE AFFECTIONATELY INSCRIBED. 



JOSEPH T. O'CONNOR. 



PREFACE. 

FOR a number of years past successive classes of 
students have urged the writer to issue in book 
form his own notes of lectures upon the diseases of the 
nervous system, given at the two homoeopathic medical 
colleges in New York. 

It is in response to these requests that the following 
pages have been put into book form. They are an 
amplification of the descriptive part of the lectures and 
a condensation of the anatomical details introductory 
to them. 

The office of lecturer in a medical college is not only 
to give to his hearers a digest of the accepted text 
books on his subject, but also to note the advances made 
in his subject by investigators and clinicians the world 
over, and to select from these such results as seem 
worthy of acceptance for the advancement of the 
student. 

Matters of purely academic or speculative interest 
have been omitted from the following pages except 
when their presentation would seem to conduce to a 
readier apprehension of related principles or to assist 
the better in memorizing important facts. 

As the lectures are for students and practitioners of 



8 PREFACE. 

homoeopathy, other methods of treatment are not given 
except as allusions in cases not amenable to homoeopa- 
thic medication as laid down in the Organon of Hahne- 
mann. Hence the importance of diagnosis and a 
knowledge of the underlying pathological changes in 
any given case form a prerequisite to any attempt at 
cure. To apply homoeopathic therapeutics from the 
symptoms of a disease admittedly incurable (except 
experimentally) is to do homoeopathy a grievous harm. 
Within its limitations Homoeopathy is invincible; 
to enlarge its domain in even a slight degree is, it is 
hoped, not a visionary conceit, but in the writer's 
opinion is possible with accurate records of cases giving 
unassailable proofs of correct diagnosis and the use of 
corroborated clinical as well as pathogenetic indications 
for the use of our remedies. 



TABLE OF CONTENTS. 



Introductory. 

The Examination ........ 17 

Electro-Diagnosis -------- 27 

Peripheral Nerves -------- 39 

Anatomy of Nerve Fibre - - - - - - 39 

Degeneration of Nerve Fibre ------ 39 

Neuritis ----- ... 42 

Multiple Neuritis - - - - 55 

Neuralgia -_...--- G8 

Trigeminal Neuralgia ------- 68 

Tic Douloureux ------- 70 

Sciatica --------- 77 

The Spinal Cord -------- 86 

The Reflexes ----- 95 

Diseases of the Spinal Cord - - - - - - 101 

Spinal Meningitis - - - 105 

Myelitis ... - - - 111 

Syphilis of the Spinal Cord - - - - - - 114 

Compression Myelitis ------ 116 

System Diseases of the Spinal Cord ----- 122 

Poliomyelitis anterior acuta ------ 122 

Primary Degeneration of the Motor Path - 127 

Spinal Progressive Muscular Atrophy ... - 129 

Amyotrophic Lateral Sclerosis - - 131 

Locomotor Ataxia - - - - - - - 134 

Ataxic Paraplegia - - - - - - - 149 

Hereditary Ataxia ------- 151 

Spastic Paraplegia ------- 153 

Non-Systemic Diseases of the Spinal Cord ... - 156 

Multiple Sclerosis ------- 156 

Acute Ascending Spinal Paralysis ----- 160 

Caisson Disease -------- 161 

Tumor of the Spinal Cord - - - ... - 165 

Syringomyelia .-__.-.- 168 

Hydromyelia - ... . . - - 171 

Spinal Irritation - - - - - - - - 173 



IO TABLE OF CONTENTS. 

The Cranial Nerves - - - - - - - 176 

The Ophthalmoplegias - - - - - - J 96 

The Pupil ... - - 192 

Oculo-motor Paralysis ._..--. 202 

Progressive Facial Hemiatrophy - 207 

Peripheral Facial Paralysis ------ 209 

Meniere's Disease ------- 219 

The Brain 226 

Progressive Bulbar Paralysis ------ 237 

The Cerebral Cortex — Cortical Areas - - - - - 247 

Anaemia of the Brain - - - - - - 262 

Hyperemia of the Brain .___-. 263 

Cerebral Meningitis -------- 265 

Cerebro- Spinal Meningitis ...--- 272 

Chronic Hydrocephalus - - - - - - - 275 

Abscess of the Brain ..._-_ 277 

Apoplexy -------- 280 

Apoplexy from Vascular Occlusion ----- 288 

Brain Tumor --------- 295 

Brain Syphilis ------- 306 

Cerebral Infantile Paralyses ------- 308 

Acromegaly - .-..-.- 315 

The Cerebellum -------- 317 

Cephalalgia — Headache ------- 319 

Vertigo --------- 322 

Tropho-Neuroses -------- 325 

Progressive Muscular Dystrophy - 325 

Progressive Neurotic Muscular Atrophy » - - - 330 

Neuroses - • -..._-. 332 

Facial Spasm - - - - - - 332 

Torticollis -------- 334 

Habit Spasm -...-.. 33^ 

Epilepsy - .... . ■ . . 337 

Migraine -------- 350 

Chorea --------- 355 

Paralysis Agitans ------- 361 

Tetany --------- 364 

Myotonia Congenita - - - - - - 368 

Hysteria - - _.-.... 371 

Hystero-Epilepsy ------- 383 

Neurasthenia --------- 387 

Traumatic Neurose3 - - - - - - - 396 



NERVOUS DISEASES 

WITH HOMOEOPATHIC TREATMENT. 



INTRODUCTORY. 



npO medical students and indeed to many medical 
practitioners the term Nervous System carries the 
idea of infinite depth, of inextricable complexity and of 
insurmountable difficulty. 

While these terms are perhaps truly applicable to 
certain parts and functions of the nervous system, yet 
so much is known of other parts and functions that the 
student of the nervous system is only hampered and 
discouraged in his work by having too prominently 
in mind the difficulties and complexities mentioned. 

The nervous system is made up of parts morpho- 
logically alike in type and which perform functions of 
similar character, that is, to produce, to carry and to 
receive nervous impulses. 

Such statement, however true literally, only con- 
tinues the difficulty in studying the nervous system 
in health and disease. In illustration it may be said 
that all secretory organs have one function, that of 
secreting from the materials presented to them certain 
substances for certain definite purposes, yet no one 
would attempt the study of all the secretory organs as 



1 2 INTRODUCTORY. 

members of one system merely because they all have 
the one common function of secretion. 

Just as one secretion differs from another in com- 
position and physiochemical activity, so nervous im- 
pulses differ among themselves, motor voluntary 
impulses being widely different from sensory involuntary 
ones and the latter differing again among themselves, 
so that an olfactory sense impulse may be utilized by 
the chemist as an aid in his analysis or an auditory 
sense impulse by the physicist in his investigations — 
yet all are manifestations of nerve-force. 

Our knowledge of the specialized nervous functions 
of different nerve tracts and masses of nerve cells has 
been obtained largely by experimental methods on 
low r er animals (atrophy method, method of develop- 
ment, method of secondary degeneration) but the 
results so obtained could not be applied to the human 
nervous system without the corroborative and confirm- 
ing facts of pathological investigation in man, when 
accurately recorded symptoms and their progress during 
life were thus explained. 

Notwithstanding such remarkable results, it may be 
said that the essential nature of disease is, except in 
cases of microbic or of toxic origin, still a mystery. 
Many diseases of the central nervous system are impro- 
perly so designated, as in invasion of the brain structure 
by a growth from without. 

The neurone theory has given to the nerve cell and 
its neuraxone (axis cylinder process) and its dendrites 
(protoplasma processes) a quasi independence that has 



IXTRODUCTOEY. 1 3 

long been foreshadowed. The mode of transmission of 
nerve impulses from a central neurone to a peripheral 
one is still a matter of discussion, yet the opinion most 
generally held is that there is actual contact of the end- 
branchings of the neuraxone of the first with the 
dendrites of the latter. 

In actual practice the mattter may not be one of 
importance, yet any conception of the inter-relation 
of nerve units forming part of one system may offer 
at least a working hypothesis for the explanation of 
the ready action of correctly chosen highly attenuated 
remedies. 

The independence of the nerve cell as an organ, 
while explaining many conditions observed in the 
course of certain nervous diseases, does not fully meet 
the question raised regarding the action of our attenu- 
ations, but the theory of the continuity of protoplasm 
throughout the whole organism, as elaborated by C. 
Heitzmann, and later by Biitschli, has been more re- 
cently advanced by a recent observer,* whose con- 
clusions are summed up as follows: " The facts 
seem to warrant present belief that the living sub- 
stance of all organisms is one physiologically con- 
tinuous, living, plasma, homogeneous throughout in its 
intrinsic powers and properties, but having varied local 
and temporary habits of self-expression, which are 
largely and inextricably correlated with physical and 
chemical conditionings of its form and composition." 



* The Living Substance as such : and as Organism. By Gwendolen Foulke 
Andrews. Supplement to Journal of Morphology, Vol. XII, No. 2. 



14 INTRODUCTORY. 

Through the agency of the continuous living sub- 
stance we can at least picture to ourselves the un- 
doubted action, often within a few moments, of highly 
attenuated drugs, but just as in the case of the higher 
vertebrates a limb or member when removed cannot 
be reproduced, so we must consider the nerve cell as 
an organ which, when destroyed, cannot be renewed. 

Hence the necessity to the homoeopath of an abso- 
lute diagnosis in order to determine just what part 
of the nervous system has undergone destructive 
change (as discovered by pathological investigation), 
and the limitations thereby set for restorative action 
through the influence of drugs. 

The Halmemannian view of the patient as a sick 
individual, and not merely as the bearer of some one 
ill-acting organ, is well set forth by the same in- 
vestigator, who says that the u true organism is the 
invisible vesicular substance [continuous protoplasm], 
whose mass limits coincide of necessity with those of 
the living being; that all of the multiple parts and 
powers, functions and organs of living units are, and 
primarily were, of and for the substance as such, 
and only partially and incidentally for the animal or 
plant." 

From the foregoing we can readily deduce the 
scientific reasonableness of Hahnemann's dictum to 
select the remedy according to the totality of the 
symptoms, and especially those of remarkable or pe- 
culiar qualities, the conditions of amelioration and 
aggravation of symptoms or other modalities, which 



INTRODUCTORY. 1 5 

are the manifestations of the living, underlying con- 
tinuous vesicular substance. 

To select a remedy, especially in chronic dis- 
seases, the prescriber must have at his command 
something more than a Compendium or Condensa- 
tion of our Materia Medica. The Encyclopedia and 
its Index or Symptom Register make the storehouse 
of our knowledge in this direction, with such ad- 
ditional provings as have since its publication appeared 
in our journals or in Transactions of the National and 
State Societies. 

The homoeopathic remedies recommended in the 
following pages (in italics) are in the potencies from 
6th to 30th, except where otherwise specially desig- 
nated. 

To the writer the question of attenuation, as such, 
is of far less importance in curing disease than the 
Hahnemannian injunction to not repeat the dose as 
long as the previous dose is still acting. But in 
waiving discussion of the question of potency, the 
writer does not wish to be considered as justifying 
doses of tincture or of Ix trituration of powerful 
drugs, in amounts equalling the usual doses of the 
old school. 

All adjuvants to medicinal treatment, included under 
the general term hygienic, should be employed. 
Their presentation and method of use do not fall 
within the scope of this book. But in this con- 
nection it may not be amiss to urge the physician 
to inquire concerning the use of tooth powders and 



1 6 INTRODUCTORY. 

washes, toilet articles, mineral waters, etc., many of 
which contain medicinal substances in amounts far 
beyond those existing in our 3d attenuation, and 
which cannot fail to introduce activities antidotal to 
a remedy in use, or productive of new symptoms, 
which, if not traced to their cause, must be mis- 
leading to the strict prescriber. 

The dosage and method of employing antipathic 
or palliative remedies in cases confessedly incurable 
are not given in the following pages; they will be 
found in the allopathic works. 

The systematic employment of electricity (in its 
different modes), as subsidiary to homoeopathic treat- 
ment, must be studied in the text books of that 
branch of medical science. Its use as a method of 
diagnosis has, however, been given in condensed form 
in the cases where such method is necessary. 

For a more thorough knowledge of the anatomy of 
the Nervous System than is given within the limits of 
these pages, the student is urged to study Prof. 
Edinger's Lectures on the Structure of the Nervous 
Central Organs, or Prof. Obersteiner's Guide to the 
Study of the Structure of the Nervous Central Or- 
gans. Of both of these, American translations have 
been published. 



The Examination. 

The functions of the nervous structures are so 
many and so various that a general outline of the 
methods to be followed in examining a case, to deter- 
mine the presence or absence of a nervous affection, 
must be given in some detail. 

Affections of the nervous system may be manifested 
by changes in sensation, whether of the peripheral 
sensibility or of the special senses ; by changes in the 
motor functions of different parts of the body ; by 
changes in the calibre of the blood vessels of a part, 
with consequent pallor in one case or redness in an- 
other ; by alteration of glandular activity; by changes 
in the conditions of nutrition of the tissues and con- 
sequent atrophy or hypertrophy of a part ; and in 
alterations in the psyclie, that is to say, in the mental 
and emotional parts of our being. 

Change in sensation may be a loss, complete or 
partial, or it may be an exaggeration of sensory im- 
pressions. 

Loss of sensation is termed anaesthesia ; when the 
strongest impressions are not perceived, the anaes- 
thesia is complete, when they are but dimly per- 
ceived, so to say, it is incomplete : total and partial 
anaesthesia mean respectively that all, or a part only, 
of the body or of a limb is anaesthetic. 

"When used without qualification and in relation to 



1 8 THE EXAMINATION. 

the periphery, the word anaesthesia refers to the ordinary 
sense of touch. But we have other peripheral sen- 
sations than those of touch. We can recognize cold 
and warmth, and we know what pain is. Whether 
a distinct set of nerve fibres and end organs exist 
in connection with the sense of pain or not, is a 
disputed point, yet it is known that pain sensations 
pass up the cord by a different pathway from that 
taken by the ordinary tactile sensation ; in disease the 
former may be lost while the latter is retained. 

There is no real hyperesthesia as a real exagger- 
ation of ordinary tactile sensibility. When we read 
of hyperesthesia we know that algesia or pain sen- 
sation is meant — a touch is perceived as pain. 

Analgesia means loss of the power of perceiving 
pain as such. In such cases the skin may be cut or 
pierced through without any painful sensation follow- 
ing, while the sense of touch is retained. When the 
power of perceiving painful stimuli is not lost, but 
is only lessened, we use the term hypalgesia. 

Loss of the temperature sense, or thermansesthesia, 
means loss of the power of recognizing differences of 
feeling produced by the application of a cold body 
and a hot one to the periphery. There is anaesthesia 
to cold alone or to heat alone in some cases, and 
there may be dysesthesia of the temperature sense 
in which cold is felt as hot or vice versa or either 
may give rise to some different pain sensation. 

The sensations of the parts beneath the skin have 
been greatly studied, yet with but little addition to 



THE EXAMINATION. 1 9 

our knowledge. The peripheral mixed nerve fibres 
pass between muscles and through them and the 
cellular tissue, so that they must be affected in all 
tests such as that of estimating the amount of pres- 
sure made by a weight placed upon the hand lying 
on a table. Estimating the weight of an object held 
at arm's length may be by the effect on the nerves 
of the coverings of the joints, or by the amount of 
contraction of muscles needed to overcome the pull 
of gravity. So the sense of position of our limbs 
(without looking at them) tells us just where they are, 
whether straight or bent, etc. An experimenter can 
place one arm of his subject behind the back, fix the 
fingers and hand in some definite arrangement, and 
if the subject have the proper sensibility of the deep 
parts with no interruption of conduction to the brain, 
he can of his own volition move his other hand and 
fingers (still without the aid of the eyes) into the 
same relative position. This sense is called the mus- 
cular sense, and although the term has been attacked 
as being inappropriate and misleading, yet it gives 
a definite idea, and no better term has been proposed. 
Loss of muscular sense is shown by ataxia, the 
latter word meaning absence of co-ordination. No 
voluntary action can be done by one muscle alone, 
several enter into producing a movement, and their 
shares in the extent of activity vary. To initiate a 
voluntary movement, or even such as has become 
automatic, the higher centres must know in just 
what amount of relaxation or contraction the required 



20 THE EXAMINATION. 

muscles are, as well as the similar states in the oppo- 
nents ; then the proper impulse to contraction in the 
one direction, and to relaxation in the other, being 
made, the movement is accomplished not by stages 
or by jerks of the separate muscles, but co-ordinately. 
When, as in the ataxic, the information mentioned 
above is not in possession of the higher centres, the 
movement may be made, indeed, but it is done 
awkwardly and with evident irregularity. 

Ataxia may be of three kinds — spinal, cerebellar 
and peripheral — the latter being as much due to 
weakness of the muscles as to interference with sen- 
sory nerve impulses. Spinal and cerebellar ataxia will 
be considered in the sections on the spinal cord and 
cerebellum respectively. 

The prefixes hyper-, meaning excessive ; hypo- or 
hyp-, meaning diminution; ana-, meaning complete loss 
and dys-, meaning perversion or falsity, may be used 
with all the qualities of changed sensation. 

At times in disease one touch may be felt as if 
repeated — the prefix poly- is here used ; at times a 
touch made upon one side is felt as if made on the 
other — this condition is termed allocheiria. 

In testing sensation no special apparatus is needed. 
A bit of absorbent cotton rolled into a loose wisp 
may be lightly drawn upon the skin, the patient's 
eyes being covered. He is then required to answer 
if he has felt it and to say where. If anaesthesia 
appears to exist, the examiner's finger may be drawn 
lightly over the spots or territory, and if still no sen- 



THE EXAMINATION. 21 

sation is felt, then the touch may be made heavier. 
Anaesthesia to the cotton but not to the finger would 
be classed as hypsesthesia. 

Next, the pain sensation is to be tested. A needle 
is used to lightly prick the skin ; if no painful sen- 
sation is felt the needle may be passed deeper or 
finally through the skin. If sensation is felt at the 
first light pricking, of course no loss of the pain 
sense exists. 

For testing the temperature sense two test tubes 
are used, one containing hot water, the other pieces 
of ice or, in the absence of ice, water as cold as 
can be obtained. Both test tubes should be dry on 
the outside. They are to be applied in irregular al- 
ternation and the subject is required to' say in each 
case whether the hot or the cold tube has touched 
him. The hot water soon becomes cool in the test 
tube and requires renewal. 

In all cases when testing sensation the eyes of the 
patient should be covered, so that he may not be 
misled into believing that he feels when he does not. 
When using the cotton or finger let him state first 
that he feels it, as the examiner should not ask "did 
you feel that!" 

To poorly educated persons the word foot means 
often anywhere from the toes up to the knees ; in 
such cases the subject may be required to point out 
the spot where the touch was made. 

Areas of anaesthesia should be marked on the skin 
with ink or an aniline pencil and figured in the re- 



22 THE EXAMINATION. 

cord. All variations from normal sensation should be 
recorded. 

Paresthesias are sensations that are entirely sub- 
jective, that is, they are not the result of external 
influences. They are sensations of burning, prickling, 
"pins and needles", freezing, etc. They may be as- 
sociated with other forms of abnormal sensation and 
often precede the occurrence of anaesthesia. The sen- 
sation may be actual pain of the kind described. 
Like everything wholly subjective there are no tests 
for paresthesia. 

Alteration in motility of any part of the body does 
not require an elaborate system of testing. When 
paralysis exists it is shown by inability of the patient 
to move the paralyzed part. The paralysis may be 
complete or partial, the latter condition being indi- 
cated by the word paresis. 

Testing the strength of a limb or part is best 
done by the examiner's own muscles. For the upper 
limb, the patient is told to grasp the examiner's first 
three fingers and then to squeeze as hard as pos- 
sible. The same procedure is to be done with the 
other hand. Difference between the two will be 
recognized by the examiner at once. Even if both 
sides are paretic the examiner can after a little 
experience recognize the fact. 

Next, the flexor power of the arm is to be tested. 
If the patient flexes the arm as completely as he 
can, the examiner putting his left hand on the shoul- 
der in front, pulls down or extends the flexed arm 



THE EXAMINATION. 23 

with his right. The amount of force requisite for 
this is inversely proportional to the amount of par- 
alysis. Of course if there is total and complete 
paralysis the patient cannot flex the arm or can only 
make a feeble effort at doing so. Weakness of the 
flexors or extensors of the wrist is tested by over- 
coming the patient's effort to put the muscles in 
action. 

The extension of the arm is tested by having the 
patient extend the arm fully, the examiner then 
trying to overcome it by doubling up the arm, if pos- 
sible. The fingers may be tested in a similar manner, 
but more information will be obtained by requiring 
the patient to open the fingers, to separate them 
widely, to touch with the thumb successively the tips 
of the fingers of the same hand. 

Testing the subdivisions of the lower limb may be 
carried out in a similar manner. 

Testing the muscular strength is of . greater value 
to the examiner in cases of paresis than in those of 
complete paralysis, the latter being self-evident on 
the patient's attempting a movement. 

Hypertonicity of muscles is shown by rigidity of 
the limb, and the rigidity is difficult to overcome by 
the examiner at first ; it does yield after some effort, 
and then the limb is easily bent. On straightening 
it again the weakness is evident until nearly in full 
extension, when extension is completed suddenly. 

Tremor is a condition of alternate contraction and 
relaxation of opposing muscles of hand and arm, neck 



24 THE EXAMINATION. 

and head, or leg and foot. The extent of motion is 
small, and the recurrences from 4 or 5 to 10 or 12 
in the second. If no tremor is evident, it may be 
elicited by having the patient hold the hand out with 
the fingers widely spread. The procedure will usually 
bring out a tremor if it exist at all. Test the patient 
further by telling him to hold the hand still; if the 
tremor increases thereby, he should now be tested 
by directing him to take from a table a glass of water 
and taste it. If tremor begins with his taking up the 
glass, and it increases in the extent of the oscillations 
as it nears his mouth, he has what is called inten- 
tional tremor. 

The motions of chorea, athetosis and in general 
convulsions need no test ; in the latter, however, the 
pupils should be examined, when possible, for the 
reaction to light. 

Contracture may be tested by endeavoring to over- 
come it. In . hysterical cases the examiner generally 
finds a perceptible increase of the spasm acting 
against his efforts. In organic contractures pain is 
produced in the endeavor to overcome them. Con- 
tractures due to anatomical shortening of unopposed 
muscles cannot be overcome except by forcible rup- 
ture of the muscle, or similar injury. 

Paralysis, with atrophy, requires the employment 
of electrical tests ; these will be found described in 
the section on electro-diagnosis. Atrophy is indicated 
by evident loss of tissue, and alteration or sinking at 
a part that normally is full. The relative part of 



THE EXAMINATION. 25 

the other side may be used for comparison, unless 
it too has been similarly affected. 

Loss of symmetry of the two sides of the face may 
be evident at first sight, or if slight, may require 
tests. Here, the patient is directed to separate the 
lips and show the teeth, to blow as if blowing out a 
candle, to close the eyes, to raise and then contract 
the eyebrows. Hemiplegia, peripheral paralysis of the 
facial nerve, hemiatrophy of the face, hysterical spasm 
of one side of the face, give different results with 
the above tests, which will be described under the 
proper headings. 

Testing the special senses requires different tests. 
For taste, the four qualities, salt, sour, bitter and 
sweet, are employed, solutions being applied to the 
edge of the tongue on its anterior two-thirds. The 
substances used are simple syrup, a solution of com- 
mon salt, extract of gentian, and very dilute hydro- 
chloric acid. Application of each solution is to be 
made by a separate camel's hair pencil to the tongue, 
which is kept protruded until the taste sensation de- 
velops (or a reasonable time if it does not). The 
acid solution should be applied last, as it dulls the 
power of tasting. The patient is warned not to talk 
during the whole experiment, lest the solutions spread 
over the tongue, and when he notices a taste sen- 
sation, he selects from a card on which are written 
or printed the words sweet, bitter, salt, sour, the 
one that he has perceived. Each half of the tongue 
is to be tested by itself. (Groldscheider.) 



26 THE EXAMINATION. 

Testing the olfactory nerve is done by holding 
a small vial containing some well-known odorous 
material, such as oil of peppermint or oil of lemon, 
before one nostril, the other being closed. On 
drawing in a whiff of it the odor will be perceived 
if the olfactory nerve is intact. Disease of the mem- 
brane may reduce or abolish the olfactory power. 
(Groldscheider.) 

Tests in connection with eye and ear will be con- 
sidered in treating of the respective nerves. 



Electro-Diagnosis. 

Although the subject of electricity in neurology 
in general is not within the plan of this book, yet 
the use of the electrical current in the diagnosis of 
nervous disease must be described with its methods. 

When a current of electricity is passed through 
a motor nerve or muscle the related muscle contracts, 
as soon as the circuit is completed, if the current 
be of sufficient strength. A difference in results is 
noted when the current strength is increased and 
change of poles made. Normally, using galvanism, the 
negative pole or cathode being on the muscle, (the 
positive or anode on some indifferent part of the body) 
there will result contraction with less strength of cur- 
rent when the circuit is completed than when the poles 
are made to change places or when breaking the 
circuit. With increasing strength of current the fol- 
lowing is the succession of contractions produced 
under the differences of arrangement just named. 
Cathodal closure contraction ; anodal closure contrac- 
tion ; anodal opening contraction ; cathodal closure 
tetanus. This series is expressed in tabular form and 
abbreviated as follows : 

I. CaCC. 
II. AnCC. 

III. AnOC. 

IV. CaCT. 



28 ELECTRO-DIAGNOSIS. 

The last term means cathodal tetanus contraction, 
because with increasing current strength the contrac- 
tions become more powerful and tend to prolong, until 
finally they are here continuous or tetanic. 

The strength of current causing a contraction 
should be determined by a proper meter in the 
circuit. As the unit of current strength is the am- 
pere, and as only small fractions of an ampere are 
used in medical electricity, the meter is arranged to 
show thousandths of an ampere and hence is termed 
milliamp er emet er . 

The electrode placed on some indifferent part of 
the body when testing, should be of definite surface; 
Erb's normal electrode has a surface of 10 square 
centimeters. The differentiating electrode should be 
small, Erb's being a series of three, spherical in shape 
and graduated in size, the largest being about the 
size of an average pea. 

The electrodes, well wetted in warm water, being 
placed in position and the negative on the nerve or 
on the part of the muscle at which its nerve is nearest 
the surface, (the handle of the differentiating elec- 
trode should be provided with an interrupting arrange- 
ment, so that the current can be made or broken at 
the will of the examiner) a weak current is turned 
on. As the current increases, contraction will be 
noted in the muscles supplied by the nerve if the 
differentiating electrode be over the nerve trunk; or 
in a muscle if its motor point should have been selected. 
Using the strength of current that brings the first 



ELECTKO-DIAGNOSIS. 29 

appearance of contraction, then by changing the pole 
by means of the pole changer the small electrode 
becomes positive and again the current is made and 
broken. If no contraction is observed it is clear that 
the negative closure contraction is greater than the 
positive, either closing or opening, which, as has been 
shown, is normal. If on the other hand, with the 
same current strength the positive give better con- 
tractions than did the negative closure, it is equally 
clear that the influence of the latter is less than that 
of the former — which is abnormal. 

The faradic current, so-called, is in no wise dif- 
ferent in nature from the galvanic. The secondary 
coil being generally used, the current is an induced 
one, and as it is only present when some change of 
current strength takes place in the original galvanic 
current derived from the cell which "runs" the far- 
adic battery, a mechanism (the so-called vibrator or 
hammer) to produce very rapidly alternating makes 
and breaks is introduced. Contraction is caused by 
the secondary current just as in the case of the 
current from an ordinary galvanic battery, but before 
the muscle has time to relax a new flow of current 
conies and the contraction remains as long as the 
vibrator is acting. 

Negative and positive, although existing in the far- 
adic current, are not diffentiated in diagnostic use ; 
but a better contraction is produced by the negative 
than by the positive. 

When a motor nerve is severed the portion distal 



30 ELECTRO-DIAGNOSIS. 

from the point of section begins to degenerate, which 
process, according to Erb's investigations, is complete 
at the end of two weeks and in some cases earlier. 

The electrical reactions have in that time altered 
in different ways. From the nerve, both faradic and 
galvanic contractility gradually lessen, until at the end 
of the second week they have disappeared. In the 
muscles supplied by the nerve, faradic contractility 
follows a parallel course, but often (not always) the 
galvanic contractility gradually lowers until near the 
end of the second week and then becomes increased 
and increasing reaches its apex at about the end of 
the third week ; it then slowly falls, but still keeps 
above the normal, till about the end of the tenth 
week in cases that rapidly recover, to the end of the 
twentieth week in case of moderate severity, and in 
those that are not to recover it does not reach the 
normal level until the end of the fiftieth week. After 
these dates, respectively, the fall continues in the first 
until the end of the fifteenth week, when it begins to 
rise again ; in the second it falls to the end of the 
fiftieth week and then slowly rises. While in the case 
not to recover it ascends to the end of the tenth 
week and then descends to finally disappear by the 
end of two years. 

The accompanying figures from Erb show graphic- 
ally the changes just described ; in addition they 
show that recovery of a nerve after complete separa- 
tion (or degeneration) takes at least six weeks from 
the beginning. 



ELECTRO-DIAGNOSIS. 



31 



Motility. 



Galv. 
Farad. 



Degener- Atrophy and nuclear g 
ation of proliferation of W>*j 

nerve. muscle. p£ 



Cirrhosis. 



3 4 



9. 10 11. 12 WEEKS. 



z S Ga ! v - 

S3 { anQ 
Z ( Farad. 







r^ 
























1 


fjs 


<> 








? 


* 


iJuu 


i^S^I 



The first ordinate shows occurrence 

of the lesion and cessation of 

motility ; the star indicates the 

Fig. 1. return of the latter, the waved 

line indicates qualitative change. 



Degener- 
ation of Atrophy, etc. 



Regeneration. 



1. 2. 3. 6. 10. 18. 20. 25. 30. 35. 40. 45. 50. 55. 




Fig. 2. 



Paralysis with late return 
of motility. 



Degener- ,r • • u • Complete dis- 

ation of Atrophy, nuclear proliferation, cirrhosis. appearance. 

nerve. 



Motility. 

i s Galv - 

§ \ Farad. 

g> ( Galv. 

S3 I and 
£ ( Farad. 



2. 10. 20. 30. 40. 50. 60. 70. 80. 90. 100. 







J 




























iUi 


^ 


/ 





Incurable paralysis ; no return 
Fig. 3. or motility. 



Nerve? Degeneration and atrophy R eration . 

1 c of muscle fibre. & 



Motility. 
£ (Galv. 
§ (Farad. 
« f Galv. 

u S an< l 
£; ( Farad. 



000 


1 






> 


f 


p^ 













._t 1 






|ttUiU iau 








'wuwuaa 

























Fig. 4. 



Partial ED ; probably no de- 
generation of nerve. 



$2 ELECTKO-DIAGNOSIS. 

Degeneration of a nerve is shown by alterations in 
the contraction of its related muscle when the former 
is tested by either current; the contractions become 
weak and finally cease even with strong currents, re- 
action to the galvanic current continuing for a while 
after that to the faradic current has ceased. This 
loss of reaction through the nerve is termed an in- 
direct quantitative change. 

When the differentiating electrode is placed on a 
muscle supplied by a degenerated nerve it is found 
that instead of the negative pole giving the better 
response the positive often does so or at least may 
cause an equally good contraction. This is called 
serial or qualitative change. 

Another typical change in the contraction of degen- 
erated muscles is the absence of the quick, sharp, 
momentary character of the normal muscle's contrac- 
tion, it being now slow and lagging. This is called 
a modal change and, if present, occurs with galvanic 
current only. 

The reaction of degeneration (expressed by the let- 
ters RD) is therefore known by the existence of the 
changes just mentioned or, to recapitulate them: the 
muscle contracts slowly and sluggishly ; it responds bet- 
ter to the positive than to the negative pole (or at 
least as well) and, indeed, at times in the earlier 
stages of the process, more readily to small amounts 
of current ; and finally the faradic reaction of both 
nerve and muscle is lost. 

A partial reaction of degeneration is said to be 



ELECTKO-DIAGNOSIS. 



33 



present when, without any alteration of the normal 
polar succession, the contraction is weaker than normal 
and for both currents, and is slow and dragging. It 
is found in slight cases of peripheral motor nerve 
degeneration. 

The motor points accessible on the surface have 
been marked on the body by Erb, Ziemssen and 
others. Because of their importance the figures and 
explanations are given on this and following pages. 



M. frontalis. 

First branch of facial nerve. 

M. corrug. supercil. 

M. orbic. palp. 
Nasal muscles. ( ' 
M. zygomatici. 
M. orbic. oris. | 
Second branch of facial nerve. 
M. masseter. 

M. levat. menti. 

M. quadr. menti. 

M. triang. menti. 

Nerv. hypogloss. 

Third branch of facial. 

M. platysma. 
Hyoid muscles. | 

M. omohyoid 



Nerv. ant. thorac. 
(M. pectcralis). 




M. temporalis. 

First branch of facial n. 
Trunk of facial nerve. 
N. auric, post. 
Second branch of facial n. 
Lower branch of facial n. 
M. splenius. 

M. sterno-mastoid. 

N. accessorius. 
M. levat. ang. scap. 
M. trapezius. 
N. post, thoracic. 

N. circumflex. 



N. thorac. long. 
(M. serratus magn). 



o Supra-clavicular 

'c point— Erb's point. 

£ (M. deltoid., 

•5 biceps, brachialis 

anticus and su- 
^ pinator longus). 

Fig. 5. 

MOTOR POINTS OF FACE. 



34 



ELECTRO-DIAGNOSIS. 



M. brachialis ant 



M. biceps. 
N. muse, cutan. 



M. deltoideus ant. 




M. lumbricales 

M. adductor brev 

M. flexor brev. 

M. opponens 
M. abductor brev, 

N 
M. flexor long 

M. flexor digit, sublimis 

M. flexor carpi radial 
M. flexor digit, profund. 

M. pronator radii 

N. median. 



M. lubricales. 



M. opponens minimi digit. 
M. flexor minimi digit. 
M. abductor minimi digit. 
M. palmaris brevis. 



ulnaris. 



M. flexor carpi ulnar. 



UPPER EXTREMITY.— ANTERIOR ASPECT. 



ELECTRO-DIAGNOSIS. 



35 



M. inteross. I, 2, 3,4. ) 
(N. ulnaris.) f 



M. abduct minimi 
digiti. 




extensor long, pollicis. 
M. extensor brevis pollicis. 
M. abductor long, pollicis. 



M. extensor indicis. 

M. extensor minimi digiti. 



M. extensor communis digitor. 
M. extensor radialis brevis. 



M. supinator longus. 
M. extensor carpi ulnaris. 
M. extensor radial, longior. 
M. supinator longus. 



M. brachialis. 

N. radialis (musculo-spiral). 



' M. tricps. 



M. deltoid. 
' X. circumflo 



Fig. 7. 
UPPER EXTREMITY.— POSTERIOR ASPECT. 



tf 



ELECTRO-DIAGNOSIS. 



N. obturator. 
M. pectineus. 

M. adductor magnus 
M. adductor longus 



N. peroneal. 

M. tibialis anticus. 
M. extensor commun. digitor. 

M. peroneus long. 

M. peroneus brevis. 

M. extensor prop, pollicis 



M. extensor digit, brevis communis 




M. tensor vagin. femoris. 



| M. quadriceps'femoris. 
M. rectus femoris. 

M. crureus. 

M. vastus externus. 



M. vastus internus. 



M. gastrocnemius. 
M. soleus. 



M. peroneus brevis. 

M. abductor minimi digit. 



M. interossei. 



Fig. 8. 
LOWER EXTREMITY.— ANTERIOR ASPECT. 



ELECTRO-DIAGNOSIS. 



37 




M. gluteus. maximus. 



N. ischiadicus 

(great sciatic). 
M. adductor magnus. 

M. semitendinosus. 

M. semimembranosus. 



N. tibialis. 



M. gastrocnemius (external). 
M. gastrocnemius (internal). 



M. flexor commun. digit. 
M. flexor longus pollicis. 
N. tibial. 



Fig. 9. 
LOWER EXTREMITY.— POSTERIOR ASPECT. 



Since degeneration of the central neurone does not 
pass on to the peripheral neurone, it follows that the 
reaction of degeneration excludes central disease, as 
it also does functional trouble. The site of the lesion 
may be the anterior gray horns of the cord (ganglion 
cells), the motor nerve roots or the nerve fibres. It 
is not present in primary disease of the muscles (mus- 
cular dystrophies) except late in the disorder. It 
is found in neuritis of all kinds, unless when very 
slight in degree ; in poliomyelitis anterior acuta, in 



38 ELECTRO-DIAGNOSIS. 

myelitis transversa if the anterior gray horns are 
much affected ; in bulbar paralysis, and amyotrophic 
lateral sclerosis, in affections implicating, by pressure 
or otherwise, the cells of the anterior gray horns or 
those of the motor nerve nuclei in the medulla; in 
syringomyelia, and after traumatic heematomyelia, and 
in progressive muscular atrophy of spinal type. In 
the progressive forms mentioned the reaction is usually 
PRD rather than complete RD. 

In prognosis the electro-responses of nerve and 
muscle are of some importance. " Under like con- 
ditions — i. e., in one and the same disease from the 
same cause, the lesion is more severe, the duration 
of the affection will be the longer, the outlook for 
complete restoration will be the poorer the more com- 
plete and typical the RD is and the more advanced 
its stage. Thus, partial reaction of degeneration is 
more favorable than the complete RD, and the later 
stages of RD more unfavorable than the earlier ones." 
— Erb. 

Special reactions to electrical stimulation are found 
in myotonia congenita and tetany. They will be de- 
scribed in treating of those affections. 



Peripheral Nerves. 



Anatomy of Nerve Fibre.— Degeneration 

of Nerve. 

Every nerve fibre originates in a nerve cell, and 
is, in fact, the extension of the axis cylinder process 
of the cell. Whether the prolonged axis cylinder 
ever divides in its course into two or more fibrils, 
although such view has been advanced, is not yet 
positively decided. In any event, the fibril soon after 
it leaves the cell receives a covering termed the 
myeline sheath, which covering is continued to the 
termination of the fibre. 

Outside the myeline sheath there is on the 
peripheral nerve fibre another termed the connective 
tissue sheath, or sheath of Schwann. It is a delicate, 
yet dense, connective tissue envelope, which, at some- 
what regular intervals in its length, undergoes con- 
striction, thrusting away, as it were, in two directions 
the myeline, and pressing itself closely to the axis 
cy finder. At such points (constrictions or nodes of 
Ranvier) the axis cylinder can be seen, in a properly 
prepared specimen, uncovered by myeline. Between 
every two such constrictions is found a flattened, 
somewhat elongated, nucleus on the inner surface of 
the membrane. The sheath and its nuclei appear to 
be of the highest importance in determining the re- 



40 ANATOMY OF NERVE FIBRE. -DEGENERATION OF NERVE. 



generation of a peripheral nerve after injury or other 
lesion; the absence of this sheath and its nuclei in 
the nerve fibres of the central nervous system thus 
explains the irreparability of destructive changes in 
such fibres. 

The myeline sheath, after being pre- 
pared for microscopical examination, 
shows certain incisures, placed at an 
angle of about 45° to the long axis 
of the fibre. 

These are termed incisures of 
Schmidt-Lantermann, and are believed 
to be non-existent in the living nerve, 
but their occurrence at somewhat regu- 
lar intervals, and in definite direction, 
leads to the view that there is 
normally some structural differentiation 
at their sites. 




18 



The nutrition of a nerve fibre 
n 9 e f at t n h^ n iatTer a ; kept up through trophic influence, or 



Fig. 10. 

Fig. io (from Gowers) 
exhibits the structure of 
nerve fibre. I. and II. 
medullated, III. non- 
medullated fibres. Ac is 
the axis cylinder or neu- 
raxon ; M is the myeline 
sheath ; S is connective 
tissue sheath 
nucleus 
IS an 
Schmidt ; N a node of • 1 "I 1 1' 1 1 O O j_ ' j_ 

Ranvier.' The myeiine possibly by direct transfer ol nutrient 

sheath appears black, x * * 

Itain. ec smic acid material from its originating cell. When 
a peripheral nerve fibre is cut across, the distal, or 
cut-off part, undergoes degeneration, most rapid in 
the interannular segment suffering the lesion, and 
next, in point of time, at the peripheral endings. 
The process of degeneration is a breaking down of 
the axis cylinder and the myeline sheath, the former 
disappearing, the latter being transformed into masses 



ANATOMY OF NERVE FIBRE. -DEGENERATION OF NERVE. 41 



or globules resembling oil, with granular 
debris, all finally disappearing. The nuclei 
of the connective tissue sheath increase 
in number, this increase, however, ceasing 
when the myeline within has been trans- 
formed into small droplets. There then 
remains only the collapsed connective 
tissue sheath. 

Regeneration of the nerve occurs from 
the proximal cut end, the axis cylinder 
advancing along the course of the sheath 
of Schwann, the addition of the myeline 
envelope being slightly behind the pro- 
gressing end of the axis cylinder. The 
process can be materially hastened in 
cases where a gap exists between the cut 
ends by suturing the ends together. 

Consideration of the nerve cells and 
nerve endings is reserved for the section 
on diseases of the central nervous sys- 
tem. 



Fig. 11. 

Fig. 11 shows the de- 
generation of nerve fibre 
(from Gowers). At A 
the protoplasm and nu- 
clei are increased, the 
myeline is breaking up, 
the process being more 
advanced near the nu- 
cleus n. In B the break- 
ing up has gone on to 
the formation of glob- 
ules. In C the latter 
are much smaller, and 
man)' have been re- 
moved, so that the fibre 
is narrow. In D all the 
products of degenera- 
tion have been removed 
from considerable 
tracts of the sheath. 



Neuritis. 

As the terminology of the word indicates, this means 
inflammation of a nerve. Theoretically, at least, any 
nerve may be the subject of the inflammatory pro- 
cess, but practically, certain peripheral nerves and 
plexuses are especially prone to inflammation. The 
causes of such inflammation may be arranged in three 
groups, i. e., toxic, from without the body; auto-toxic, 
from within, and traumatic. 

Traumatism, most commonly excessive or prolonged 
pressure, causes a localized neuritis, that is to say, 
in one or more nerves that have been thus subjected 
to the injury ; the toxic, from without the body, and 
the auto-toxic, from within, may and usually do, in- 
volve in the neuritic process the nerves of more than 
one member ; and when the toxic effect is not great 
or the resistance of the nerve to the morbid influence 
is great, a slight trauma may be sufficient to determine 
a neuritis limited to the part of the body so sub- 
jected to the latter influence. 

The term peripheral nerve is often used indifferently 
for the nerve trunk and for the ultimate nerve fibres 
of which the latter is made up. And if the process 
of inflammation attack first the connective tissue 
about the nerve fibrils and the bundles of the same, 
the term interstitial neuritis is used ; when the pro- 
cess is limited to the nerve fibrils themselves it is 



NEURITIS. 43 

said to be a parenchymatous neuritis. Clinically, no 
distinction between these two forms is practicable. 

When a nerve becomes inflamed it begins to under- 
go a softening and alteration of structure both in its 
myeline sheath and in its axis cylinder; the in- 
flamed spot thus undergoes degeneration so that 
here no nerve structure is discernible under the 
microscope. The portion of the nerve distal from 
this point undergoes degeneration even without exten- 
sion of inflammation, according to the law of second- 
ary degeneration, which tells us that any part of a 
nerve fibre if separated from its origin goes into 
degeneration. As the motor fibres of a peripheral 
spinal nerve take their origin in the large ganglion 
cells in the anterior gray horns of the cord, they 
degenerate outward from the point of the lesion. 
The sensory fibres of the same nerves arise from the 
posterior spinal ganglia and hence degenerate upward 
and downward. The older view that secondary de- 
generation goes in the direction in which the affected 
fibre carries its nervous impulses would thus seem to 
be not true of the peripheral sensory fibres. 

As the cylinder axis of a nerve fibre is but the 
outgrowth and continuation of the cylinder axis process 
of the originating cell, the cell and its outrunning 
fibre being looked upon as a unit and termed neurone, 
it is evident that destruction of the cell is at once 
followed by destruction of the fibre. The effort has 
been recently made to prove that destruction of any 
part of a nerve unit or neurone is followed by de- 



44 NEURITIS. 

structive changes throughout the rest of the neurone 
and thus is explained an ascending neuritis even in 
motor fibres. 

Not only is the nerve fibre proper dependent upon 
its originating cell, but also the muscle fibre to which 
the motor nerve fibre is sent and in which it ends, 
undergoes degeneration with the nerve. 

There is therefore when complete degeneration of 
a peripheral spinal nerve trunk or a great portion of 
it has occurred, loss of function of all the affected 
fibres, that is to say, no impulses can be carried in 
either direction and paralysis of motion and of sensa- 
tion results on the part of the affected nerve. 

Since the nutrition of a muscle fibre is dependent 
upon the integrity of the nerve fibre ending in it, it 
follows that degeneration of the nerve fibre will be 
followed by a similar condition in the muscle cell. 
The latter becomes shorter and thinner, its striations 
more indistinct and closer together than normally ; it 
takes on a peculiar glassy appearance (vitreous de- 
generation) and if regeneration of the nerve fibre does 
not occur the muscle fibre disappears. Meanwhile 
increase of the nuclei of the sarcolemma and connec- 
tive tissue proliferation begin and in advanced cases 
the remains of a few muscle fibres in a mass of con- 
nective tissue are all that are left. The atrophy is 
usually evident to the eye in the case of superficial 
muscles. 

In many cases of neuritis the lesion does not affect 
all the fibres or the process of degeneration is not 



NEURITIS. 45 

so rapid as that of regeneration ; hence the paralysis 
may be slight in degree (paresis) for motion and 
sensation (hypaesthesia) or in the latter case there 
may be not destruction but irritation, so that parse sthe- 
sias occur in the distribution of the nerve fibres so 
affected. 

From the foregoing considerations the diagnosis of 
a neuritis may be readily deduced. The paralysis or 
paresis, the anaesthesia, hypaesthesia or paresthesia, or 
a combination of these, limited to the territory supplied 
by a mixed peripheral nerve, are sufficient to direct 
attention to that nerve as the organ whose functions 
have been interfered with or lost. Anaesthesia is, 
however, often surprisingly little in amount or limited 
in extent even after severe trauma, or lasts but a 
relatively short time. The explanation must be in 
the existence of other sensory nerve fibres for the 
same territory or a nerve anastomosis. 

In an inflamed nerve whose continuity has not yet 
been destroyed pain and tenderness are common 
manifestations. The pain is constant, with variations 
in intensity, and in mild cases or those of moderate 
severity is described as a "dead aching", which by 
its persistence becomes torturing to the patient. It 
is increased by anything that causes pressure upon 
the affected nerve, such as muscular action in the part, 
passive motion, direct pressure, etc. In severe cases 
the quality of the subjective pain may be boring, 
tearing, burning, etc. 

Tenderness to pressure along the nerve trunk is a 



46 NEURITIS. 

marked feature of neuritis, and even when in slight 
cases the pressure does not give rise to objective 
tenderness an increase of the subjective pain is often 
produced lasting for many minutes. 

Paralysis is, as has been stated, one of the results 
of interruption in the continuity of a nerve, so that 
neuritis in all but the slightest forms gives rise to 
paralysis of the muscles supplied by the nerve af- 
fected. Thus neuritis of the musculo-spiral nerve is 
readily determined by the knowledge that the ex- 
tensors of the forearm and the supinator longus are 
paralyzed. Examination of a patient should always 
include testing the different muscles as to their power 
of action under the direction of the patient's will. 

A list of the muscles supplied by the peripheral 
(spinal) nerves, as well as statements of the action of 
those muscles, will spare the reader the trouble of 
studying out this information from his Anatomy should 
his memory of the facts be faulty. 

Nerves of the Upper Extremity. Circumflex nerve. 
Supplies the deltoid, teres minor and the skin over 
the deltoid. In paralysis the upper arm cannot be 
raised, some slight amount of abduction is present 
from the action of the supra-spinatus. From the 
atrophy that occurs there is loss of the rounded con- 
tour of the shoulder by the prominence of the bony 
structures, and as the nerve supplies the structures 
of the joint the ligaments are relaxed. There is also 
to be seen and felt a gap between the head of the 
humerus and the acromion. Paralysis is to be differ- 



NEURITIS. 47 

entiated from anchylosis of the joint by the fact 
that in the latter, if passive motion be made of the 
upper arm the scapula moves also, not in paralysis. 

Musculo-spiral nerve supplies the triceps, both sup- 
inators, the muscles at the back of the forearm (ex- 
tensors, abductors and adductors), extensors of wrist 
and of first phalanges of the fingers, extensors and 
abductors of the thumb. 

In the majority of cases of paralysis of this nerve 
the lesion is near the middle of the humerus, and 
hence commonly the triceps is not affected. Because 
of the extensor palsy there is inability to extend the 
hand upon the forearm (the so-called wrist drop) and 
also a projection at the back of the hand (synovial 
sacs, bone) appears, and the first phalanges cannot be 
extended. If the arm be straightened out the forearm 
cannot be supinated. Paralysis of the supinator longus 
is best shown by causing the patient to flex the arm 
against an opposing force, when the normal bellying 
of the supinator just below the bend of the elbow 
will be found to be absent. Because of the loss of 
the opposing action of the extensors the flexors can- 
not act fully, and hence the grasp is weakened. 

Median nerve supplies the pronator teres and pro- 
nator quadratus, the radial flexor of the wrist, both 
sets of flexors of the fingers, except the ulnar half 
of the deep flexor, the long flexor of the thumb, 
the muscles of the ball of the thumb except the ad- 
ductor, the first two lumbricales and at times the 
third. Flexion of the hand on the wrist is impeded, 



48 NEURITIS. 

and even only possible with a strong inclination to 
the ulnar side ; pronation of the forearm is impos- 
sible beyond the mid-position to which it is brought 
by the supinator longus. Flexion of second and third 
phalanges of the fingers is lost but not completely in 
the ring and little fingers. The thumb cannot be 
flexed nor brought into apposition with the tips of 
the fingers. The unopposed action of the interossei 
on the last two phalanges causes hyperextension and 
subluxation of them. 

Ulnar nerve supplies the flexor carpi ulnaris, the 
ulnar half of the deep flexor of the fingers, palmaris 
brevis, muscles of the hypothenar eminence, the in- 
terossei, the fourth lumbricalis and commonly the third, 
and the adductor pollicis. In paralysis of this nerve 
the power of flexion of the hand on the forearm is 
greatly weakened, the little finger can scarcely be 
moved, flexion of the first phalanges and extension 
of the second and third are lost from paralysis of the 
interossei, but not completely in the index and middle 
fingers since these receive innervation from the median 
nerve. Lateral movement of the fingers is impaired 
and adduction of the thumb is lost. 

The musculocutaneous nerve supplies the coraco- 
brachialis, biceps and brachialis anticus muscles, the 
chief flexors of the elbow. Paralysis of the nerve 
prevents flexion of the forearm when in position of 
supination, but flexion can be done when the arm is 
pronated, by flexing the supinator longus. 

Combined palsies of the nerves of the arm are 



NEURITIS. 49 

frequently seen and arise from various causes. Disease 
or injury above the brachial plexus, or affecting the 
plexus in part or entirely, or affecting more than one 
nerve trunk below the plexus, can readily produce 
varied combinations of paralysis. Severe pressure above 
the clavicle readily affects the fifth and sixth cervical 
nerves, as they begin to enter the formation of the 
brachial plexus. Electrical stimulation at a point two 
fingers' breadth above the clavicle and one finger's 
breadth behind the sterno-cleido-mastoid muscle causes 
contraction together of the deltoid, brachialis anticus, 
biceps and supinator longus (Erb's point: supraclavic- 
ular point). A not uncommon form of paralysis of 
the upper part of the brachial plexus occurs from 
pressure made above the clavicle by the accoucheur 
in extracting the delayed head or by prolonged 
pressure during parturition on the shoulder girdle, 
thus approximating the clavicle and spinal column. 
This is known as Erb's paralysis. At birth the 
peripheral nerve fibres are poor in resisting power 
and the effect of a severe lesion then is long 
lasting and may be irremediable.* The power of the 



* In the new born child and for several weeks after birth the resistance 
to both faradism and galvanism is very high as compared to that of the adult, 
varying from 7,000 to 10, ('00 ohms during the first week of extra-uterine life. 
In addition to this, the very young individual shows but little sensitiveness 
to currents, both faradic and galvanic, that cannot be borne by the adult. 
The contractions caused in the muscles by either current, whether direct or 
indirect, differ from those in the adult in being slow and dragging instead of 
being quick and sharp. The anatomical explanation of these long known facts 
is found by A. Westphal to be due to the imperfect development of the 
nerve fibre at birth and during the first few weeks, the myeline sheath 
being absent in spots and sometimes over long stretches of nerve axis, and 
when present being thin and evidently but poorly elaborated. The inutility 
of employing electricity as an aid to diagnosis in cases of Erb's paralysis 
during the first few weeks of life is thus apparent 

Microscopical examination shows in the peripheral nerve in the very 
young, appearances very similar to those seen in the adult nerve degenerated 
after separation from its cell. The subject matter of this note is treated very 
thoroughlv by A. Westphal, in Archiv f. Psychiatric u. Nervcnkranlcheitcn, Bd. 
XXVI., Hft.'l. 



50 NEURITIS. 

muscles of the hand and lower arm is not lost, but 
the upper arm is motionless and the humerus is ro- 
tated inward, so that the forearm hangs with its ex- 
tensor side facing forwards. This inward rotation is 
stated by Goldscheider to be in the majority of 
cases not due to paralysis of the external rotator, but 
to separation of the epiphysis since the inward rotator 
is inserted lower down than the outward rotator. 

Another form of lesion of the brachial plexus is 
seen when the injury occurs from below, in the axilla, 
involving the eighth cervical and the first dorsal nerve 
as they enter the plexus. The muscles of the hand 
are paralyzed, the flexors in the forearm, and when 
the seventh cervical nerve is affected, the extensors 
of the hand are also involved. 

Intermediate forms may occur or the plexus as a 
whole be affected. 

Besides the motor paralysis, oculo-pupillary symp- 
toms may be observed when the roots are affected 
before the giving off of the rami communicantes. 

Dislocations, fractures, in the region of the shoulder 
joint, forced retraction of the shoulders, the arms 
being raised, during operations, direct pressure from 
a badly fitting crutch in the axilla, violent muscular 
activity as in throwing, etc., can produce injury to 
the plexus, and a primary neuritis of the plexus has 
been observed. 

Sensory disturbances may be slight in degree, or on 
the other hand quite marked after traumatic neuritis. 

Nerves of the lower limb. Affections of the lum- 



NEURITIS. 5 1 

bar and sacral plexuses are far less frequent than 
those of the brachial, chiefly because of their pro- 
tected situation, yet occasionally they, or some of the 
nerves from them, are the subject of special injury 
during prolonged parturition, by pressure of the for- 
ceps, or by tumors, etc. 

Anterior crural nerve paralysis renders the patient 
unable to flex the leg at the hip joint except partly 
by the action of the psoas muscle, which is not sup- 
plied by this nerve ; the extensors have no power, so 
that the leg cannot be extended upon the thigh. 
Hence standing and running are greatly impeded, if 
not prevented. 

Paralysis of the obturator nerve causes inability to 
adduct the thighs ; hence the legs cannot be crossed, 
nor the knees pressed together. 

Paralysis of the superior gluteal nerve, a rare oc- 
currence by itself, causes loss of power of internal 
rotation, abduction and extension of the thigh. 

Paralysis of the sciatic nerve causes loss of power 
in all the muscles of the leg and foot, and the power 
of flexion of the leg upon the thigh is gone. 

The peroneal or external popliteal nerve supplies 
the peroneus longus and brevis, tibialis anticus, ex- 
tensor communis digitorum, longus and brevis, ex- 
tensor hallucis longus. Its paralysis results in what 
is known as "drop foot", the foot hanging lax when 
the leg is lifted; the toes catch on the ground when 
the patient attempts to walk and the outer toes cannot 
be extended, the foot cannot be abducted nor dorsally 



52 NEURITIS. 

flexed and the outer edge of the foot cannot be 
raised. When the paralysis is of long standing the 
unopposed action of the calf muscles produces short- 
ening and consequently pes equinus. 

The internal popliteal nerve innervates the flexors r 
both long and short, of the toes, the calf muscles,, 
tibialis posticus, adductor and abductor of the great 
toe, the abductor of the little toe, the interossei and 
lumbricales. 

In paralysis of the plantar nerve flexion of foot and 
toes is lost; adduction is lessened; the patient cannot 
extend the foot nor raise himself upon his toes. II 
the paralysis be of long standing the unopposed action 
of mucles innervated by the peroneal nerve causes 
talipes calcaneus with hyperextension of first phalanges 
of the toes and flexion of second and third. 

The areas of sensory distribution ot the peripheral 
nerves will be more readily understood by reference 
to the accompanying illustrations than by any description. 



NEURITIS. 



53 




Fig. 12. 

From Hesse. The small curves mark the places of exit oi 
nerve branches through the fascia. 
N. axillaris ^circumflex. 



54 



NEURITIS. 



H 

. / ■ 

/ n.cur. 

FEM.INT. 





N.CLUNIUM 
SUP. LUMB 




6 




Fig. 13. 

From Hesse. The small curves mark the places of exit of nerve 
branches through the fascia. 

N. clunium sup. lumb.= gluteal distribution from lumbar nerves ; 
N. dun. int. sacrales=gluteal distribution from sacral nerves. 



Multiple Neuritis. 

The distinction between neuritis arising from injury 
and a neuritis of toxic origin can usually be made out by 
eliciting the history of the case. Yet the writer has seen 
cases in which the history of traumatism was obtained 
only after repeated questioning. All the non-traumatic 
forms may be safely called toxic, either endogenous or 
exogenous, the exception being possibly where the local- 
ized influence of cold is the only assignable cause. In 
one instance a ride on a hot day in the open air pro- 
duced a neuritis of the brachial plexus, and also of 
the dorsal nerves supplying the trapezius of the same 
side. General exposure to cold may cause suppression 
of cutaneous activity and consequent accumulation of 
toxic (rheumatic?) material within the body and thus 
in predisposed cases neuritis may result. 

The infectious diseases, typhoid fever, diphtheria, 
tuberculosis, syphilis, etc., can cause wide-spread neu- 
ritis, as also can septic conditions (puerperium, etc.). 
The poison of gout, of rheumatism and of diabetes 
may cause a general neuritis — but with diabetes, syph- 
ilis and diphtheria, the neuritis may be localized. 

In Japan a form of multiple neuritis has existed 
for centuries; it is there known as u kak-ke". Since 
the rice ration of the Japanese army has been sup- 
planted by wheat flour and an addition of meat the 
disease has in great part disappeared from the army. 



56 MULTIPLE NEURITIS. 

The natural inference would be that the disease is 
due directly or indirectly to faulty diet, but Dr. Albert 
A. Ashmead, of New York, who spent many years in 
Japan and who has investigated the disease, is firm- 
ly convinced that it is due to poisoning by car- 
bonic oxide, and he reports a remarkable instance of 
the outbreak of the disease on board a ship sailing 
from the Philippine Islands bound for New York, and 
plentifully supplied with good food. Bad weather 
caused exposure and fatigue, and the cargo of un- 
refined sugar began to ferment giving off C0 2 , so that 
the crew were evidently poisoned and the most virulent 
form of multiple neuritis attacked the ship's company 
causing several , deaths. Dr. Ashmead's views have led 
the writer to insist in every case of neuritis upon a 
most abundant supply of fresh air. In tropical South 
America, and also in India, a similar type of the 
disease is known under the name beri-beri. 

In these regions the affection occurs during the hot 
season, and the effort has been made to discover a 
special microbe as its originator. 

The most frequent cause of multiple neuritis in the 
temperate zones is undoubtedly the use of alcohol, 
and in every case in which the evidences of the disease 
are present no effort should be spared to trace it to 
that cause. The writer has been so often surprised 
to find, on questioning servants and other attendants, 
that a continuous use of alcoholic beverages had ex- 
isted unsuspected by the family physician, that he is 
now not satisfied in such a case to exclude alcohol as 



MULTIPLE NEURITIS. 57 

the cause, unless the testimony against such view is 
overwhelming. 

Other poisons introduced from without have un- 
doubtedly caused multiple neuritis. In such cases the 
history, usually connected with some trade or occupa- 
tion (mercury, bisulphide of carbon), or a "course" of 
drugging (arsenic, mercury,) point out the causal in- 
fluence. 

Symptoms. — Injury to a nerve trunk, as by pres- 
sure, affects first the perineurium (perineuritis) then 
involves the epi- and endoneurium and intermediate 
connective tissue (interstitial neuritis) the usual evi- 
dences of inflammation, such as hyperaemia and cell 
proliferation being found on microscopical examination. 
From pressure the axis cylinder is injured and may 
be destroyed and then occurs secondary degeneration 
of the nerve fibre. 

Primary or degenerative (parenchymatous) neuritis 
is of frequent occurrence, the neuritis beginning by 
degenerative changes in the axis cylinder, but the 
interstitial connective tissue' soon becomes involved. 

The most prominent symptom of an acute neuritis 
is pain, subjective, of the character already described 
and, objective, by pressure upon the nerve trunk and 
its ramifications. Paresthesia and hyperesthesia are 
common symptoms, while occasionally motor irritative 
phenomena, such as fibrillary contractions and cramps 
in the muscles supplied by the affected nerves are 
observed. Vaso-motor and trophic changes may be 
present ; these are redness and swelling (cedematous), 



58 MULTIPLE NEURITIS. 

herpes, " glossy" skin, bedsores, gangrene, pemphigus, 
etc., all in the distribution of the nerves inflamed. 
When the nerve is severely affected or the degenera- 
tion has advanced, hyperesthesia gives place to anaes- 
thesia or hypsesthesia, while paralysis and atrophy are 
to be expected. 

The most common form of multiple neuritis seen 
in this country is that due to the long continued use 
of alcohol in even moderate doses. Hence it is more 
frequently seen in women than in men, since the latter 
seem more inclined to get intoxicated and then cease 
for a time the use of strong drink or else have de- 
lirium tremens. In my experience, however, I have 
seen multiple neuritis so often associated with de- 
lirium tremens in the very poor half-vagrant class 
having the alcohol habit that I am inclined to think 
that the distinction holds good only for those who 
are well nourished. 

The onset of the trouble is really slow, although 
the outbreak of positive symptoms may be quite 
sudden. Vague pains and paresthesias may exist for 
weeks with some weakness in the legs and many 
digestive troubles that mislead the family physician 
in the absence of any knowledge of the real cause. 
Then some morning on getting up and walking to 
her toilet table or bath-room the patient sinks to the 
floor rather than falls, and she is found to be paralyzed 
in the lower limbs. The muscles and nerve trunks 
are tender to pressure, the pains in the lower limbs 
increase and soon the upper extremities are involved, 



MULTIPLE NEURITIS. 59 

although not to the same degree usually. The extensor 
muscles of leg and forearm are especially affected 
and the so-called foot-drop and wrist-drop are present. 
Examination may show areas of anaesthesia and les- 
sened volume of the affected parts, while the reaction 
of degeneration determines the character of the atrophy 
when it is present. The anterior crural nerve being 
affected the knee jerk is of course gone and tremor 
of hands, lips, tongue and face may appear. 

The functions of bladder and rectum are not much 
interfered with, but in my experience the stomach 
always or nearly always shows disturbance evidenced 
by thickly coated tongue and foul breath. 

In estimating the influence of the infectious diseases 
in the production of a subsequent multiple neuritis, 
place should be given to the possible toxic effects 
of alcohol prescribed during the course of the former 
disorder, and this is especially true in typhoid fever 
and tuberculosis. 

Whether the division of multiple neuritis into a 
motor, sensory and ataxic form is justified, is to the 
writer a doubtful point, since the predominantly ataxic 
or sensory forms are not at all frequent. 

The metallic poisons, lead, arsenic, silver and mercury 
can cause multiple neuritis, and of these the first two 
more frequently than the others. In such cases the 
arms are affected first, usually, and more than the 
legs, the reverse being true of alcoholic neuritis. Lead 
seems to have a selective power in affecting the mus- 
culo-spiral nerve after the branch to the supinator 



60 MULTIPLE NEURITIS. 

longus has been given off; but it also has a wide- 
spread influence upon the structures of the central 
nervous system, so that degenerative changes, especi- 
ally in the anterior gray horns of the spinal cord and 
also in the brain cortex, have been observed post- 
mortem. 

The local paralysis caused by the poison of diph- 
theria is seen in the muscles of the palate, oesophagus 
and larynx and even in the cardiac innervation. Just 
how the paralysis of accommodation occurring frequently 
after diphtheria, or of some of the external ocular 
muscles, is produced, is difficult to say. In one case 
the writer has seen a typical bulbar paralysis follow- 
ing a severe sore throat which he believes to have 
been diphtheritic. In another case a severe and 
rapidly advancing multiple neuritis followed immedi- 
ately the disappearance of paralysis of the palate mus- 
cles occurring from diphtheria. It is to be kept in 
mind that loss of the knee jerk is a common symptom 
after diphtheria. 

The association of neuritic (neuralgic?) symptoms 
with loss of the knee jerk in diabetes is not as yet 
understood. On the other hand the insufficiency of 
Trommer's or Fehling's test for sugar in the urine is 
now recognized and must formerly have led to errors 
in diagnosis* 

* Sugar. The sub-oxide of copper is precipitated by other substances 
than sugar in the urine (uric acid, kreatin, kreatinin, etc.) and lately Salkowski 
has called attention to the existence of a body termed pentose that occurs in 
the urine in certain cases, which precipitates the sub-oxide from Fehling's 
solution without boiling. The urine, so tested, shows in such cases fluorescence. 
Such urine does not undergo fermentation by the addition of yeast ; hence 
the fermentation test should always be employed as a control test in all cases 
of suspected diabetes or glycosuria. 



MULTIPLE NEURITIS. 6 1 

The diagnosis of a neuritis in a peripheral spinal 
nerve is readily made out by recognition of pain, sub- 
jective and objective, in the affected nerve, by the 
loss or impairment of function, such as anaesthesia, 
paresthesia, hypaesthesia, paralysis or paresis in the 
distribution of the nerve, and by the history of previ- 
ous injury, exposure to cold, previous poisoning, al- 
coholic, metallic, etc., rheumatic (?), or of antecedent 
infectious or septic disease, etc. Erb's paralysis has 
been mistaken for poliomyelitis. 

Multiple neuritis will be recognized by the paralytic 
and sensory symptoms in the extremities and limited 
chiefly to the distal half of each. 

Where there is a considerable degree of ataxia and 
anaesthesia it may be mistaken for locomotor ataxia, 
especially when the onset has been slow. The ab- 
sence, however, of bladder or rectal implication and 
of pupillary inaction and of a girdle sensation are 
against the existence of the latter, while the tender- 
ness of nerve trunks and muscles, the paralysis or 
paresis of the limbs and the abnormal electrical re- 
action do not belong to tabes. Lightning pains as 
seen in locomotor ataxia do not belong to an ordinary 
neuritis, yet I have seen in more than one case the 
most frightful paroxysms of pain radiating from the 
back down the arms or around the trunk, these being 
evidently due to severe irritation of the nerve roots. 

From poliomyelitis anterior the pains would be 
sufficient to differentiate a neuritis even in the 
presence of considerable atrophy, while the atrophy 



62 MULTIPLE NEURITIS. 

itself is, in the two diseases, different in distribution ; 
in the former less in the distribution of nerve trunks 
than in the muscles associated in some one definite 
action. 

In myelitis transversa there are no spontaneous 
pains unless the nerve roots are implicated; there 
is no tenderness of nerve trunks, no atrophy of 
muscles, while there is exaggeration of deep re- 
flexes, a thing not present in neuritis except in the 
very earliest stage. In myelitis lumbalis, leading to 
atrophic paralysis and loss of knee-jerk, paralysis or 
paresis of bladder and rectum is to be expected. 

The prognosis in multiple neuritis is good, pro- 
vided the cause has been removed, or in cases of 
paralysis following the severing of a nerve if the 
cut ends be in apposition, the connective tissue sheath 
of the cut ends serving as a guide or pathway for 
the new growth from the proximal uninjured part. 

Multiple neuritis has a tendency to recover, except 
in the pernicious forms, in which there is some im- 
plication of the cardiac nerve supply. In the alco- 
holic form when delirium tremens is present the 
prognosis is grave as long as the latter condition 
remains, or if pneumonia develop. Cases of multiple 
neuritis without the complications recover in a few 
months, or after many, according to the degree of 
severity and consequent amount of degeneration. 

Concerning the homeopathic treatment of neuritis, 
the general considerations as to treatment already 
^iven should be borne in mind. The causal indi- 



MULTIPLE NEURITIS. 63 

cation is always of the first importance in select- 
ing a remedy. Hence, in cases in which trauma 
(pressure, etc.) has produced a neuritis, Arnica is, 
in the writer's experience, the remedy first to be 
thought of, and should be given in a moderate po- 
tency aud not frequently repeated. Hypericum has 
received great praise for its influence in restoring 
a nerve after traumatic influences, but, in the 
writer's opinion, it has less influence than Arnica, 
possibly because it seems to have a selective in- 
fluence upon either the terminal organs of the sens- 
ory fibres, or on the posterior nerve roots as they 
enter the spinal cord. Iu several instances, where 
the only clinical presumption possible was special 
implication of the posterior nerve-roots, the remedy 
in third dilution acted admirably in relieving pain 
and bringing about a rapid cure, and in at least 
one case in which an ascending neuritis of the 
arm followed a punctured wound of a finger-tip 
this remedy in 200th seemed to be the only one 
that made the patient comfortable, even after mor- 
phine had been used in vain for this purpose. 

Other remedies, such as Rata graveolens, Rhus toxi- 
codendron, Dulcamara, Ledum palustre, or Apis melli- 
fica will be thought of should their special causal 
indications be present. 

When the use of alcohol can be fairly charged as the 
cause of a neuritis, even of severe type, there is no 
oue remedy (unless special contra-indications are pres- 
ent) so valuable as Cimicifuga racemosa given in 3d or 



64 MULTIPLE NEURITIS. 

6th ; in a local neuritis whose immediate cause is 
trauma, while the predisposing cause has been the use 
of alcohol, Arnica had better be given first, to be fol- 
lowed later by Cimicifuga racemosa. Next in rank to 
Cimicifuga racemosa are Banuncuhis bidbosus, China 
officinalis and Bryonia alba, and in more chronic cases 
Arsenicum and Lacliesis. Ledum palustre ought to be a 
valuable remedy in alcoholic neuritis, but the writer 
has not used it in the multiple affection, owing pos- 
sibly to the limitations of the direction of the pains 
produced by it. 

In other forms (non-alcoholic) of neuritis remedies 
must be chosen by the symptoms, but here again 
some cause, such as exposure to cold or wet, will 
lead the prescriber by a short-cut to the selection 
of the remedy. Rhus toxicodendron, Rata graveolens, 
Calcarea carbonica, Didcamara, Natrum sulphur icum, 
Bellis perennis and many others are to be studied for 
this purpose. 

A slight trauma may set up a neuritis in a patient 
whose nutrition is below par from causes other than 
the use of alcohol. Quite recently a patient called 
on the writer suffering from neuritis of the median 
and ulnar nerves of the left arm, caused directly by 
a woman in confinement having grasped the arm 
with great force during one of her pains. There was 
intense subjective pain, with paresis of the flexors of 
the forearm and hand. A remedy was given with 
some slight relief, and on the next visit the doctor- 
patient stated, as an odd fact, that for several years 



MULTIPLE NEURITIS. 65 

previous there had been a chronic diarrhoea which no 
remedy seemed to reach and that it had ceased since 
the existence of the neuritis. Further investigation 
showed that the diarrhoea had been caused by plung- 
ing into the sea while overheated, the water being 
very cold at the time. The diarrhoea, which had 
stopped during the neuritic attack, returned as soon 
as the neuritis was lessened by the remedy. Acting 
upon this hint, Bellis perennis was given in the belief 
that the diarrhoea must be cured first before the 
neuritis would go. The result more than justified 
this opinion, for both diarrhoea and neuritis disap- 
peared, the latter, however, not at once, for a relapse 
was caused by clapping the hands at a public en- 
tertainment. Two doses of Arnica radix, followed by 
a few of Bellis perennis, restored the patient, whose 
arm, however, had to be humored for several weeks. 

At times the location of a neuritis will enable the 
physician to select the remedy. For instance, any 
neuritis in the distribution of the nerves from the 
lumbar and sacral plexuses seems readily influenced 
by Berber-is vulgaris. If it is limited to the lesser 
sciatic, 2Esculus hippocastanum seems to be better 
indicated, and if in the anterior crural, Pdreira brava. 
The rectal symptoms of 2Esculus hippocastanum, or 
the bladder symptoms of Berber is vulgaris or of Pareira 
brava, are strong indications, even though they them- 
selves have long preceded the neuritis. 

So a deltoid paralysis (circumflex nerve) of months' 
standing, occurring in a farmer, and presumably from 



66 MULTIPLE NEURITIS. 

cold, has been relieved in a few days by Sanguinaria 
Canadensis. For a root neuritis, or trouble simulating 
this in the upper dorsal roots, Anantherum muricatum 
30 has acted in a marvellous manner in several cases. 

Of the large number of substances already men- 
tioned as causing multiple neuritis Arsenic, Mercury, 
Lead, Bisulphide of carbon, and Copper are also well- 
proven homeopathic remedies. Carbon monoxide has 
a place in the homeopathic materia medica under 
the title Carboneum oxygenisatum, but there are many 
drugs whose provings show symptoms similar to those 
of multiple neuritis. But we are not limited to 
remedies known to cause inflammation of peripheral 
nerves, and should hold in mind the characteristic 
symptoms, modalities, and especially the causal ones 
as our guides. 

The writer has known Phosphorus 6 to make a 
rapid cure of post-diphtheritic multiple neuritis, the 
selection of the remedy being made on the ascend- 
ing of sensory and motor paralysis from the ends 
of fingers and toes. The diphtheria toxine* (not 
anti-toxine), in the 200th potency, rapidly cured a 
hospital case unable to walk from post-diphtheritic 
polyneuritis. 

As to the care of a case of multiple neuritis, 
the cause, if found, having been removed, warmth 
and good nourishing food, with an addition of 
assimilable fat, are the chief things. In applying 



^Obtained through the kindness of Dr. Paul Gibier, Director of the Pasteur 
Institute, New York, and potentized for the writer by Dr. Martin Deschere. 



MULTIPLE NEURITIS. 67 

hot bottles or hot-water bags to the affected limbs, 
the danger of burning must be kept in mind, for 
the anaesthesia or hypaesthesia may prevent the pa- 
tient from appreciating the degree of heat used, 
and the tissues during the existence of the disease 
have a much lowered vitality. Troublesome ulcers 
may thus be caused. 

Motion must be avoided if it produce much sub- 
jective pain. Massage is, in the writer's opinion, 
injurious in any stage of the affection. Galvanism 
is often (not always) of marked value, but should 
not be employed, as a rule, until the acute pains 
have somewhat subsided; occasionally the anode to 
the site of great pain, the cathode in some indif- 
ferent part of the body gives great temporary re- 
lief, but at times this is for a short while only, 
and may be followed by marked and long-continued 
aggravation. The benefit from the use of galvanism 
is most in the later stages, when spontaneous pain 
has greatly lessened; the application should be 
cathode stabile at an indifferent part, anode labile 
along the affected nerve trunk, small currents of 2 
or 3 m-a for 2 or 3 minutes to each limb. In old 
cases where atrophy is markedly present, the same 
electrical treatment as that followed in poliomyelitis 
anterior should be used. When contractures exist, 
manipulation and extension of the contractured muscles 
will often overcome the deformity and bring about 
restoration of structure and function. 



Neuralgia. 

The word neuralgia means nerve-pain, but it is ap- 
plied only to pain existing in a nerve without any 
anatomical change in the latter. 

The pain in neuralgia is of different qualities; it may 
be boring, tearing, crushing, lancinating, etc. It gen- 
erally comes in a succession of outbreaks, each 
lasting a few minutes or, at times, much longer. At 
the end of the paroxysm there may be entire relief 
until a new one begins, but often there is during the 
interval a considerable substratum, so to say, of pain 
that is continuous. When all pain ceases, not to re- 
turn, the attack is over. 

An attack of neuralgia may be brought on by dif- 
ferent causes, exposure to cold being the chief one ; 
but mental excitement, excessive fatigue, error in diet, 
etc., are, at times, provocative. 

The subjects of neuralgia are neurotic or debilitated, 
or have gouty or rheumatic constitution. The affection 
first appears, in the majority of cases, in early adult 
life ; it rarely occurs before the period of puberty. 

Neuralgias may be divided into idiopathic, reflex 
and symptomatic forms, according to causation. When 
due to irritation of the nerve directly, as by a tumor 
within the skull, irritation set up by a decayed tooth, 
etc., it is symptomatic; when caused by disease of some 
distant organ it is reflex, and when no cause is assign- 



NEURALGIA. 69 

able other than a general state of the system affecting 
the nerve, it is idiopathic. 

The pathology of the affection is in donbt. It is 
easy to assume that the affection must specially in- 
volve the nervi nervorum, but the irradiation or stream- 
ing out of the pain apparently to other nerve trunks 
is best explained by locating the real seat of the 
trouble in either the posterior spinal ganglia or in the 
cells of the posterior gray horns of the cord, and ex- 
tension of irritation to other cells will send up to the 
cortex impulses of pain felt as coining from the related 
peripheral nerve. Reflex neuralgias are produced in 
a similar way and muscular spasm in the part may 
be aroused by irritation sent to the anterior motor 
cells. Growers gives an illustration showing a focus 
of softening in the pons, involving part of the sensory 
nucleus of the fifth nerve ; during life it had caused 
severe neuralgic pain in the face. 

Hyperalgesia (to a light touch) of the skin cover- 
ing the affected region is observed in many cases, but 
often firm pressure will ameliorate the pain. Tender 
points may be found in the course of the affected 
nerve, at its emergence from a bony foramen or in 
its course over a bone or where it passes through 
fascia. 

The diagnosis of neuralgia is made from the location 
of the pain in one nerve which changes place from 
moment to moment, and from the absence of evident 
organic change in the nerve (paralysis in a mixed 
nerve, anaesthesia); in neuritis pressure anywhere along 



JO NEUKALOIA. 

the affected nerve is painful, while in neuralgia if 
firm pressure be made it often suppresses the pain, 
as above stated. 

The occurrence of pain in paroxysms, with free- 
dom in the intervals between the attacks, points 
to idiopathic neuralgia rather than to organic disease 
affecting the nerve. In reflex neuralgia the distant 
cause may be difficult to discover. 

Long continuance of neuralgia may result in setting 
up some amount of organic change in the nerve. 
Eruptions such as herpes, pemphigus, etc., in con- 
nection with pain in a nerve are evidence of organic 
change in the nerve itself or its spinal ganglion, or, 
in case of the fifth nerve, in the Grasserian ganglion. 

Neuralgia of the Fifth Nerve. — Trigeminal Neuralgia. 
— Prosopalgia. — Tic Douloureux. 

This is the most common form of neuralgia, indeed 
it is more common than all other forms taken to- 
gether. It is the most typical in the characteristics 
of pain, paroxysms, free intervals, etc. 

It may attack any one of the divisions of the nerve 
or two of them or all three. 

When the first division is the seat ot the trouble 
the pain is generally over the eyebrow ; it may extend 
down the side of the nose or be felt in the eye. 
Painful pressure points are just above the supra- 
orbital foramen, on the nose near the inner canthus 
and on the bone just above the outer canthus. 

When the second division of the nerve is affected, 



NEUKALGIA. 7 1 

pressure points may be found at the infraorbital fora- 
men, at the side of the nose and on the malar bone. 
When the third division is involved, the points are 
in front of the tragus or somewhat above this, at the 
parietal eminence and at the site of the mental fora- 
men. 

The eyeball itself may be a pressure point when 
its supply from the first branch of the fifth, is involved ; 
or an ocular neuralgia may exist alone. 

In elderly persons neuralgia alveolaris in the tooth- 
less gums has been described by several observers ; 
the writer has seen loosening of a tooth (from absorp- 
tion of the alveolar process) follow an attack of facial 
neuralgia, not once, but many times in the same indi- 
vidual. The loosened tooth, if treated and kept, 
seemed to receive the brunt of such trophic change 
in subsequent attacks, but when it had finally to be 
drawn, another attack would find a fresh victim in 
a hitherto firm tooth. 

The pain in an attack of trigeminal neuralgia varies 
greatly, but in the paroxysms there is a "shooting" 
character with a "cutting" quality. At times it is 
a crushing of the most intense kind ; at others as if 
the tissues were rapidly torn through as one might 
tear a strip of cotton cloth. The peculiarity of the 
affection is its irradiation from one branch of the nerve 
to another; the supraorbital region may be intensely 
painful, but in a few moments there may be a streak 
of pain in the lower jaw or a long stab beside the 
nose or just in front of the ear. 



72 NEURALGIA. 

Or the pain may play along the face as the so- 
called "heat" lightning plays across the nocturnal sky 
— here the lancinating quality of the pain is not 
marked, but is replaced by a feeling as if the nerve 
were rapidly crushed. When this lambent character- 
istic is present the writer has observed a chilled or 
cold sensation in the nerves, and as a very severe 
attack with these peculiarities was accompanied in 
part of its course by an outbreak of herpes, he is of 
the opinion that such attacks show irritative or even 
inflammatory changes in the Gasserian ganglion. 

During a paroxysm of pain the sufferer can bear no 
external irritation — every thing is unbearable — to 
move the head or body, to open the mouth, to be 
touched near the areas of pain, all give increase of 
agony. A draft of air, an increase of light, a sudden 
noise, is intolerable, hence the myriad of suggestions 
to use hot applications or cold ones, to do this or that, 
have perhaps some beneficial effect in distracting the 
attention of the now irritable brain, become so from 
the intensity of the suffering. 

The attack may last hours or days and then gradu- 
ally disappear; or, happily, it may be cut short under 
the influence of a well-chosen remedy. 

One form of trigeminal neuralgia termed by 
Trousseau epileptiform neuralgia (a most unsuitable 
title) deserves attention. In these cases the sufferer 
is attacked with a suddenness that is appalling by an 
outbreak of pain in one of the branches of the fifth 
nerve. The suffering is of the most intense character 



NEURALGIA. 73 

and it may last a minute or two. In the agony of 
it the patient's face is drawn up, his hand goes in- 
voluntarily to the seat of pain and he remains bent 
over and immovable until it ceases. Or, unable to 
control himself, he literally runs about the room, as 
if out of his senses, or presses the painful part with 
his hand or against any object. The paroxysm being 
over, the patient is himself again, but a sudden motion > 
even in answering a question, may bring on a return 
of the pain — and indeed such patients are always in 
terror. The writer has studied out remedy after 
remedy for this trouble, but so far has failed to affect 
it. The patients having this affliction are usually in 
the latter half of life, but apart from their special 
trouble appear to be in good health. Among the old- 
school physicians the disease is considered incurable. 

The treatment of prosopalgia by homoeopathic rem- 
edies is one of the most satisfactory experiences in 
the whole domain of neurology. Of course any rem- 
edy that is specially indicated must under the circum- 
stances be prescribed, yet it so frequently happens 
that certain drugs especially influence certain nerves 
that they may almost be considered specifics. The 
side affected, the branch of the nerve, the causal 
conditions, the conditions of aggravation or amelioration, 
the underlying reflex causes, must always be taken 
into account and a study made thereon. Spigelia, 
Kalmia, Gelsemium, Magnesia phosphorica, Belladonna, 
Bryonia, Elms toxicodendron, Coloeyntli, Xatrum murla- 
ticum, and Nux vomica, have in the writer's hands been 



74 NEURALGIA. 

of remarkable efficacy. Natrum sulphuricum 6, (given 
because of the special yellow-green coating of the 
tongue, which led to further study of the case and 
brought out the history that the trouble began while 
living in a very damp house) cured a case that had 
lasted for years, and which came to the writer for 
opinion as to the advisability of neurectomy. Mer- 
curius has often been of service, and more than 
one case has been cured by removal of amalgam 
fillings in the teeth, or by changing a red-rubber 
dental plate (colored with cinnabar) to a gold one. 

The dentists refuse to believe that amalgam fill- 
ings or red rubber plates can give to the saliva 
any amount of mercury, forgetting or not knowing 
that the saliva at times contains sulpho-cyanide of 
potassium, which can readily decompose in the 
presence of mercury, and form a mercurial sulpho- 
cyanide. The sulpho-cyanide is not always present, 
indeed may only appear in morbid conditions ; vide 
Hoppe-Seyler's Physiologische Chemie. 

Cervico-occipital neuralgia. A not common form. 
The pain is as in pure neuralgia, is in the four 
upper cervical nerves, and is chiefly in the distri- 
bution of the great occipital nerve, in which region 
it is not infrequently bi-lateral. It is less par- 
oxysmal, and the exacerbations are less severe than in 
trigeminal neuralgia. It may extend down the neck 
from the jaw, involving the small occipital nerve. 

Cervico-brachial neuralgia is a rare form. The 
pain is in the nerve supply from the four lower 



NEURALGIA. 75 

cervical and the first dorsal nerves. It may affect 
any part of hand or lower arm and posterior part 
of the neck ; it is greatest in the axilla and in 
the ulnar nerve. Painful pressure points may be 
found in the axilla, at the posterior border of the 
deltoid and on the ulnar nerve behind the elbow, 
and on the front of the wrist. There is more or less 
constant pain, with very acute paroxysms, often 
brought on by moving the arm, or by exposure to 
cold. It is stated to result from injury, but such 
a history ought to lead to examination for inde- 
pendent or associated neuritis of the plexus. 

The dorsal nerves are mixed nerves ; each di- 
vides into a large anterior branch and a small pos- 
terior one, the first dorsal contributing largely to the 
brachial plexus, its anterior or intercostal portion 
being small. The first six of the anterior branches 
are intercostal nerves, and are exclusively distributed 
to the chest and its coverings ; the last six supply 
the walls of the chest and abdomen. 

Intercostal neuralgia is an affection frequently 
seen, generally in women who are debilitated or neur- 
asthenic. The nerves oftenest affected by neuralgia 
are from the fourth to the eighth. Painful pressure 
points are at the side of the related vertebral 
foramina, in the axillary line and near the sternum. 
The pain is more or less continuous, but has severe 
exacerbations, sharp or stabbing in character, felt in 
the course of the nerves. The left side is most 
frequently affected, but both sides at times are 



76 NEURALGIA. 

involved. Exposure to cold is a common ex- 
citing cause ; the neuralgia may be produced symp- 
tomatically by disease of the vertebrae or ribs, by 
growths within the spinal canal, etc., and by ex- 
ternal injury to the chest wall. 

It is to be distinguished from pleurodynia, which 
is a pain located in one spot, and not following 
the course of an intercostal nerve ; there is great 
tenderness on pressure. The pain in pleurodynia is 
aggravated by respiratory movements of the chest, and 
is probably due to a neuralgia of the pleural nerves 
(Gowers). 

Neuralgia mammalis. Mastodynia. Pain in the 
breast may be idiopathic or symptomatic (tumor). It 
occurs mostly in women, but has been observed in 
the male. It affects one gland only, but may involve 
the lateral as well as the anterior branches of the re- 
lated intercostal nerves. Terrillon has observed it in 
women, either stout or slender, whose dependent 
breasts have not been supported, thus by interference 
with the local circulation directly causing the affec- 
tion. The same writer considers ill-fitting corsets to 
be a cause of the trouble. The paroxysm of pain 
may last but a few minutes, or may extend over 
hours ; it may spread to the back, the axilla, the in- 
ner side of the arm, or even to the fingers ; at times 
it is of great intensity. A painful pressure point has 
been observed below and to the inside of the nipple 
or at the upper outer edge of the gland. The nipple 
itself may be extremely tender to touch. Mastodynia 



NEURALGIA. J J 

occurs after puberty, during pregnancy, or during lac- 
tation, and may give rise to much apprehension 
through fear of cancer. 

Liumbo-abdominal neuralgia involves the lumbar 
nerves or their derivatives. It is seen in women 
chiefly, and in the middle period of life. Little 
is known of its etiology, but cold, exposure and in- 
trapelvic disorders irritating the cords of the lumbar 
plexus, are among the causes ascribed. 

The pains, dull and continuous, become sharp in 
the paroxysms, are located in the lower back, and 
stream down the buttock or on the upper edge of 
the pelvis, or to the hypogastrium, inguinal region and 
the genitals, on one side. They may involve the 
inner or outer side of the thigh. 

Painful pressure points may be found outside of 
the first lumbar vertebra, above the crest of the 
ilium, over the middle of Poupart's ligament, or even 
at the lower surface of the labium majus (or scrotum). 

Anterior crural pain is not a rarity ; it has been 
observed in connection with bladder troubles and in 
conditions of so-called lithaemia. 

Of neuralgias in the nerves of the sacral plexus 
the chief one is sciatica. It is nearly as frequent 
as trigeminal neuralgia, occurs in men four times as 
often as in women, and in the majority of cases be- 
gins between the ages of 30 and 50. It rarely be- 
gins before 20. 

The predominance of males among the sufferers 
from sciatica is ascribed to their special conditions 



yS NEURALGIA. 

of life, such as exposure to cold, wet, over-exertion, 
etc. Living in damp habitations, sleeping in wet 
clothing or on damp ground, working in water, sudden 
cooling while over-heated, have repeatedly caused an 
outbreak of the disease. 

Traumatism plays also a role. Falls upon the but- 
tocks, pressure of a tumor within the pelvis, of 
the gravid uterus, of the forceps during labor, even 
large accumulation of faeces in the rectum, have 
been assigned as causes. Direct pressure, long con- 
tinued, as in sitting on a hard bench, has been a cause. 

Sciatica may be symptomatic of vertebral disease, 
tumors within the spinal canal, meningitis, etc., but 
in such cases it is more apt to appear bi-laterally. 
It is not infrequently an accompaniment of diabetes 
and often the condition of pain varies directly with 
the increase or decrease of sugar in the urine. 

The pain may begin suddenly, but often for a day 
or two preceding there is discomfort about the hip 
and thigh on movement. It is an aching with parox- 
ysms of lancinating or tearing, extending at times 
downward to the foot or upward to the sacral region ; 
in most cases the pain is in the back of the thigh 
and in the calf, but it may be chiefly in the anterior 
part of the leg or in the foot. 

Painful pressure points may be found at the sciatic 
notch, between the trochanter major and tuber ischii, 
in the middle of the thigh, in the popliteal space, 
along the fibula, in the middle of the calf, behind 
the external malleolus and on the back of the foot. 



NEURALGIA. 79 

The lesser sciatic may be involved and then there 
will be superficial tenderness on the back of the thigh 
and extension of the pain to the sacral region. 

The pain is usually increased by motion and by 
pressure and often the patients assume peculiar posi- 
tions when sitting or standing. At times the pelvis 
is raised on the affected side and the spine curved 
toward the well side ; at times both conditions are 
reversed. Various explanations of the scoliosis thus 
produced have been made, paresis of the erectores 
spinse, spasm of the same, and implication of the 
nerves of the lumbar plexus, being among the latest. 

The disease may last a few weeks or may continue, 
with periods of remission, during many months. 

Pathology. Gowers considers that most cases of 
primary sciatica are cases of neuritis. Some wasting 
of muscles occurs and changes in their electrical re- 
actions are found at times — conditions belonging to 
neuritis and not to neuralgia. Changes in the nerve 
sheath, at times extending to the interstitial tissue, 
have been found in most of the cases examined. The 
neuritis is thus a perineuritis. 

The diagnosis of sciatica consists chiefly in exclud- 
ing any distant cause of the pain. Such causes have 
been mentioned on a preceding page. Between a 
sciatic neuritis and a pure neuralgia of the nerve, 
the tenderness of the nerve trunk, the subjective pain 
in it and the wasting of muscle are in favor of the 
former; the pain in branches of the nerve rather 



80 NEUKALGIA. 

than its trunk and a history of previous attacks of 
neuralgia elsewhere, are in favor of the latter. 

The prognosis is good as to cure in cases of sciatica 
not due to symptomatic causes mentioned on page 78. 
In such cases the sciatica is only curable by removal 
of the cause. Homoeopathy has had many and brilliant 
successes in the treatment of the disease. 

Coccygodynia is a neuralgia of the last sacral and 
the coccygeal nerve, the pain being chiefly felt at 
the tip and on the posterior aspect of the coccyx. It 
occurs oftenest in women and results from dislocation 
of the coccyx during labor, from a fall on the 
buttocks or similar injury, and from disease in the 
region itself. It is seen chiefly in hysterical or neu- 
rasthenic persons. It is said to arise spontaneously, 
but this is rare. 

Treatment of neuralgia is a matter of studying out 
the remedy. Some of the remedies for trigeminal 
neuralgia have been mentioned on page 73 ; to men- 
tion all the possible remedies would be to recapitulate 
the names of a majority of our drugs. Experience, 
however, has shown that many cases present repe- 
titions of indications for certain drugs, so that the 
list of those most often found serviceable in trigeminal 
neuralgia becomes short relatively. In recent cases 
Aconite is indicated when its special symptoms are 
present, especially restlessness and anguish, and when 
exposure to sharp cold has been the cause. Bella- 
donna; the pain shoots to different parts, there is 
redness of the face and aggravations from light, 



NEURALGIA. 8 1 

noise, touch (but hard pressure may relieve), a jar, 
or draft of air. Other remedies that have brought 
rapid relief at the writer's hands are Kalmia, Spigelia, 
Plantago major (pains sharp and "play" chiefly be- 
tween the teeth and the ear), Magnesia phosphorica, 
Nux vomica, Menyanthes (relief by hard pressure with 
the hand), Mercurius and Cimicifuga. 

In patients who are subject to trigeminal neuralgia 
Arsenicum, Argentum nitricum, Phosphorus, Platinum, 
Stannum or Staphisagria will frequently be found in- 
dicated. Malarial cases may require Natrum miiria- 
ticum, especially after abuse of Quinine, while Cedron 
and Quinia sulphate among their symptoms have marked 
periodicity in the return of pain. 

In ciliary or ocular neuralgia Allium cepa, Paris 
quadrifolia, Croton tiglium have repeatedly been of 
value, while Gelsemium, Belladonna, Nux vomica and 
Mezcreum are highly recommended. 

In occipital neuralgia Cimicifuga, Picric acid, Am- 
monium picricum and Carbolic acid; in brachial and 
intercostal neuralgia Aconite, Spigelia, Anantherum muri- 
catum 30, Chclidonium (right side) and Ranunculus 
bulbosus (region of upper ribs), Bryonia, Kali carhonicum 
and Bumex crispus (region of lower ribs, left side) 
have been efficacious. 

In mastodyiiia Belladonna, Chamomilla, Conium, Croton 
tiglium, Ilelonias, Cimicifuga and Phytolacca have been 
recommended. 

Under the heading "sciatica," Knerr in the repertory 
to Hering's Guiding Symptoms gives seventy-three 



82 NEURALGIA. 

remedies, most of which are marked with the sign of 
cure. They embrace practically all the remedies al- 
ready mentioned as indicated in neuralgia. In the 
writer's hands Gnaphalium has acted curatively in a 
remarkable way more than once, and if unable to 
obtain satisfactory indications for some other drug, he 
would choose, as the remedy for sciatica, Gnaphalium. 
Good results have followed the use of Colocynth, Rhus 
toxicodendron and Ammonium muriaticum, 

Repetitions of sciatica wear upon the patient's 
strength and gradually bring about gastric, intestinal 
and circulatory disturbances, which in turn react un- 
favorably upon the affected nerves. In severe cases 
of this kind the great constitutional remedies will do 
more in the direction of giving lasting improvement 
than remedies chosen simply on the local symptoms. 

Coccygodynia is so often associated with other pains 
in nervous or hysterical women that its symptoms 
must be taken with others in prescribing. When the 
trouble is alone, the causal indication of trauma (bruise 
or dislocation) will call for Arnica, or Rhus, or Ruta. 
Kali bichromicum, Cistus, Antimonium tartaricum, Paris 
quadrifolia and Petroleum have with other remedies 
been reported as valuable in the treatment of the 
affection. 

In case of failure of remedies to help, manipu- 
lation of the coccyx through the rectum or vagina 
may undo a displacement, or removal of the bone 
may be resorted to, a procedure that has been fol- 
lowed in some cases by success, in others by failure. 



XEUKALGIA. 83 

Morton's neuralgia, or metatarsal neuralgia, is 

located at the metatarso-phalangeal joint of the 
fourth toe, usually. It is of traumatic origin. Lat- 
eral pressure upon the joint structures by a narrow 
shoe, and consequent forcing the end of the fifth 
metatarsal bone against the fourth, compressing an 
intercurrent branch of the plantar nerve, or treacling 
through a thin sole upon a stone, with direct in- 
jury to the part, are common causes. Some amount 
of dislocation of the metatarsal bone undoubtedly 
exists in many cases. 

Cure is to be obtained by removal of the cause — 
that is, by wearing thick-soled, roomy and well-fit- 
ting shoes ; roomy and well-fitting stockings are 
equally essential. 

During an attack relief will be found by manipu- 
lating the last three toes by drawing them for- 
ward and downward and reversing the procedure : 
the patient will soon find out which brings the de- 
sired relief. When at home the patient should wear 
as much as possible roomy slippers having felt insoles. 

When once well-established, the affection is, even 
after disappearance by removal of the cause, liable 
to return from too long standing, or taking too long 
a walk. 

Remedies for recent cases are Arnica, Hypericum. 
Rhus toxicodendron and Ruta; for cases of long existence, 
besides these, Sabadilla and Cannabis Indica. 

Erythromelalgia is the name given to a special 
affection of the extremities, usually the feet, in which 



8 4 



NEURALGIA. 



the feet (especially the soles) are red, somewhat 
swollen and extremely painful, both when at rest and 
in motion. In the cases seen by the writer there was 
a history of an excessively long walk under conditions 
of fatigue or of other depressing influences. At first 
the trouble may appear in attacks, but soon it be- 
comes more or less continuous, is often worse at night 
and on walking, and is better in cold weather. Lewin 
and Benda, after a study of all the cases reported, 
have come to the conclusion that it is not a disease 
sui generis, but that in some of the cases it is a 
special form of neuritis, in others it is part of a 
general neurosis, and in still others it is an accom- 
paniment of brain or cord affection. 

The cases seen by the writer have been apparently 
neuritic. One case was cured by Sabadilla; the 
others did not remain under treatment. The most 
promising remedies are Sabadilla, Phosphorus and Can- 
nabis Indica. Squilla has the symptom " soles red 
and sore when . walking." 

Acroparesthesia. This term Schultze, of Bonn, 
applies to an affection long known to neurologists 
and described commonly as "numb fingers." The 
trouble seems to be a distinct disorder and is seen 
most often in those whose work compels them 
to have the hands in water frequently. It is seen in 
washerwomen, in dishwashers in hotels, and one case 
of the writer's was a man who handled ice con- 
stantly. There is undoubtedly impaired nutrition as 
an underlying condition in all cases, and in many 



NEURALGIA. 85 

the use of beer. The symptoms are usually prickling 
or "pins and needles" sensation, affecting the ends 
of the fingers, sometimes extending up into the hand 
and sometimes limited to the ulnar or the median 
distribution. A similar condition has been described 
as affecting the feet. The symptoms are worse at 
night and from exposure to cold. The disease is very 
intractable in many instances. 

There is no known pathology, the disorder being 
held by different observers as a neurosis, an acro- 
neuritis or as a vaso-motor affection, the latter because 
in some instances there is either shrivelling of the 
ends of the fingers or slight alteration in color. 

Treatment should be directed by the general symp- 
toms, the special symptoms not often leading to the 
selection of any efficient drug. Electricity, especially 
faradism, is helpful in lessening the annoying prickling, 
but galvanism seems to be more potent in the direc- 
tion of cure. 

Among our remedies, however, a not inconsiderable 
number have caused numbness of the fingers ; chief 
among these are Phosphorus especially, Kali carbonicum, 
Lachesis, Staphisagria, Crocus saliva, Nux vomica and 
Silicea. 



The Spinal Cord. 

The spinal cord is that portion of the central 
nervous system placed within the spinal canal. It 
extends from the level of the upper border of the 
axis to that of the lower border of the first lumbar 
vertebra in the adult; in the new-born infant it reaches 
to the lower border of the third lumbar. 

Around the central canal, which is all that remains 
of the cavity of the original neural tube, the gray 
matter of the cord is located in such manner that 
its cross-section has something of the appearance of 
the letter H. The white matter is outside the gray 
and is composed of medullated nerve fibres. The 
cord is incompletely divided into two lateral halves 
by an anterior fissure and a posterior septum of glia 
tissue. 

By reference to the illustration the location of the 
different fibre-tracts, cells, etc., can be readily seen. 
In the anterior limbs of the gray matter are placed 
several groups of large ganglion cells whose axis 
cylinders gathering together at successive levels form 
the anterior or motor nerve roots. Similarly, from 
the cells of the posterior spinal ganglia, the nerve 
fibres form at successive levels the posterior or sensory 
nerve roots, which enter the cord at the extremity 
of the posterior horn, or in the column of Burdach ; the 
latter divide into ascending branches which pass upward, 



THE SPINAL CORD. 



87 




Fig. 14. 

Fig. 14, from Edinger, giving general idea of the structure of the spinal cord. A segment of the 
spinal cord is shown, the posterior spinal nerve roots of the segment represented (diagrammatically) 
as arising from single cells (of the posterior spinal ganglion), the centrally directed ones enter the 
cord, some directly into the column of Burdach, some into the gray posterior horn. The fibres or 
collaterals that end at or near the level of entrance are seen to do so, as a brush-work surrounding 
cells in the gray matter from which new fibres arise ; fibres which are to ascend higher than the level 
of entrance appear as if cut off. 

The anterior spinal nerve roots are seen to arise from the ganglion cells in the anterior gray 
horns ; near one motor cell, a fibre from the posterior root is seen, ending as a brush work, thus 
completing the reflex arc or reflex mechanism. 

In the gray matter the anterior, lateral and posterior cornua or horns are sufficiently well desig- 
nated ; Col. ves.= vesicular column of Clarke. In the right half of the picture a fibre from the 
posterior root is seen ending in a brush work about a cell of Clarke's column, from which a new 
fibre arises and passes to the extreme lateral edge of the cord, there to turn upwards as part of the 
direct cerebellar column of white matter. The gelatinous substance of Rolando, the zona spongiosa 
and the zona terminalis are plainly indicated. 

In the white matter Pyramid, vord. St. B. and Pyramiden Seitenstr. B.=the anterior or direct 
and the lateral or crossed pyramidal tracts, respectively. 

Kleinhirn-Seitenstrang-Bahn=direct cerebellar column ; Fascic. ant. lat.= anterolateral or Gow- 
ers' column; Seitenstr. and Vorderstr.= lateral tract and anterior tract respectively ; Grund-Bundel 
= ground bundle or basis bundle, and Grenzschicht=limiting layer, both of short fibres probably ; 
the columns or fasciculi of Burdach and Goll are indicated by their names. 



giving off on the way collaterals, and end in a brush work 
in the neighborhood of cells at the top of the cord, and de- 
scending branches which passing forward at the level of 
entrance descend some distance and end in bushlike 
expansions near the cells of the anterior gray horn 



THE SPINAL CORD. 



of one or both halves (forming a segment of a reflex 
arc) or about the cells of the column of Clarke. 

The fibres of the column of Burdach are displaced 
toward the median line by new fibres entering at higher 
levels, thus forming the column of Groll. 




Fig. 15. 
Fig. 15. — Course of some fibres and their collaterals. From an antero-posterior longi- 
tudinal section of the spinal cord of a human embryo 20 centimetres in length. a=fibres 
from the median division of a posterior root ; b= their bifurcations in the most anterior part 
of the gelatinous substance of Rolando ; c= longitudinal fibres of Burdach's column ; d= 
collaterals. From Lenhossek. 

The fibres entering the gray matter have a short 
course ; they end in brush-work near cells in the gray, 
from which new fibres arise and pass upward in the 
columns indicated in the illustration. 

The long fibres (primary neurones) of the columns 



THE SPINAL CORD. 89 

of Goll and Burdach respectively, are for the trans- 
mission of muscular sense impulses ; those of the 
direct cerebellar tract are possibly for transmission 
of similar impulses, but may have to do with impulses 
from the organs of vegetative function, since the vesi- 
cular column of Clarke begins (and consequently the 
direct cerebellar tract) at the level of the lowest 
pair of sympathetic ganglia ; the fibres of the antero- 
lateral column carry up, probably, the sensory im- 
pulses of pain and temperature. The exact route of 
the impulses of ordinary tactile sensibility may be by 
a part of the postero-external column, but may be 
in part through the anterior ground bundles. 

The paths for voluntary motor impulses from the 
cerebrum are in the pyramidal tracts, the anterior or 
direct pyramidal tract coming from the cerebral hemis- 
phere of its own side, the lateral or crossed pyramidal 
tract from that of the opposite cerebral hemisphere. 
The fibres in each case on reaching the destined 
level, turn into the anterior gray horn of the same 
side and end in brush work about the large ganglion 
cells there, from which the fibres of the anterior 
(motor) nerve roots arise. The view that the fibres 
of the direct pyramidal tracts cross to the opposite 
anterior horn through the anterior commissure is now 
denied. (Lenhossek.) 

The existence of collaterals from the fibres of the 
column of Goll has not been observed by Lenhossek. 

Short fibre tracts occupy the white areas of the 
cord as yet unmentioned, i. c, the residues of the 



90 



THE SPINAL CORD. 



anterior and lateral columns. These, in part, carry 
fibres connecting different segments of the cord or op- 
posite halves of the cord (via anterior commissure). 

The mechanisms in the cord for reflex actions of 
different kinds are centres with afferent and efferent 
connections. Their positions are given on page 100. 

The nerve cells in the spinal cord are many, and 
can be divided into groups. They are in the gray. 

The large ganglion cells of the anterior gray, horns 
have a very peculiar structure, as shown in Figure 
16a. They are star-shaped or multipolar. Their 
processes divide and subdivide at a little distance 



■vSN 



Ml 







/^ 




Fig. 16 a. 

Fig. )6a. — Large motor ganglion cells from anterior gray horn 
of an ox. The axis cylinder process or neuraxon is downward. 
The other processes are dendrites. Only the beginnings of the 
processes are shown. The complicated details of the cell 
body are shown here ; in Fig. 16b the processes are shown at 
great length, but the Golgi stain there used leaves the details 
of the cell body undistinguished. Highly magnified. 



THE SPINAL CORD. 



91 




Fig. 16 b. 
Fig. 16b. — Motor or ganglion cell from the anterior gray horn of 
the spinal cord of a human foetus, 30 centimetres in length. A 
collateral branch (Golgi) from the axis cylinder or neuraxon is 
seen ; near the latter the star is placed. From Lenhossek. Highly 
magnified. 

from the cell and end in arborization. Their axis 
cylinder process passes forward as an anterior or 
motor nerve root. 

The cells are in groups, each group being in re- 
lation to a special muscular function or class of muscles. 

In the middle and lateral areas of the gray matter 
are placed many cells, which give rise to fibres that 
pass outward and turn up in the lateral and antero- 
lateral white columns. 

At the junction of the posterior horn with the 
middle portion of the gray is a column of cells 
known as the vesicular column of Clarke. The cells 



92 



THE SPINAL CORD. 



send out fibres that pass laterally to the edge of the 
cord, and passing up form the direct cerebellar 
tract, posterior to the antero-lateral tract. Many of 
the cells are sensory and are parts of new neurones 
taking and carrying the sensory impulses brought in 
by sensory peripheral nerve fibres. 

At the head of the posterior gray horn is seen, 
under the microscope, a different appearance from the 
rest of the gray. It is called the gelatinous sub- 
stance of Rolando, and contains many small cells and 
a very fine "felt work" of fibres, some of which 
appear to get into the posterior and lateral columns. 

In the region anterior to the gelatinous substance 
and near the cells of Clarke's column are found most 
plentifully the so-called Golgi type of cell. (Figure 
17.) It is noted for the branching of its processes 




Fig. 17. 



Fig. 17. — A Golgi's cell from the posterior horn of the spinal cord of a human foetus, 35 centi- 
metres in length. The star is placed near the axis cylinder or neuraxon. From Lenhossek. Highly- 
magnified. 



THE SPIXAL COED. 



93 



immediately on their leaving the cell's body, and 
often showing a remarkable prickly or varicose ap- 
pearance. The nenraxon soon after leaving the cell 
body divides dichotomonsly at right angles, and after 
suffering one or more further subdivisions terminates 
in very fine free ends. Lenhossek says that these 
cells are not found in the spinal cord of reptiles, 
amphibia and fishes ; they are found in the larger 
mammalians and are most perfect in man. 




Fig. 18 

Fig. 18. — A glia cell from the spinal cord of a child aged 9 months. Lenhossek. 
Highly magnified. 

The supporting tissue of the nervous structures of 
cord and brain is made up of cells which are small 
in body with a relatively large nucleus and with many 
fine processes or outrunners. These exist in great 
numbers in all parts of the central nervous system. 
and the interlacing or felting of the processes forms 
a delicate yet tough support for the nervous elements. 
They are known as glia cells, or ''spider" cells, or 
Deiters cells. Thev are not transformed connective 



94 THE SPINAL CORD. 

tissue cells, since they are derived from the ectoderm, 
and they form the septa, even the posterior central 
septum being made up of them. According to Len- 
hossek there is no connective tissue within the central 
nervous system, except such as may accompany the 
bloodvessels as adventitia. 

The blood supply of the cord may be considered 
as coming from three great plexuses ; the first being 
the so-called anterior spinal artery, derived as two 
branches from the vertebrals and soon uniting to a 
common trunk, continuing downward in the anterior 
sulcus and receiving reinforcements from the ascending 
cervical, intercostal, lumbar and lumbo-sacral arteries. 
The other two are derived above from the vertebrals 
and are similarly reinforced from the posterior branches 
of the arteries named. These two plexuses course one 
on each postero-lateral aspect of the cord. The 
branches from the three plexuses supply the interior 
of the cord, those from the anterior artery being 
distributed chiefly to the gray matter, those from a 
postero-lateral plexus being considerably smaller and 
supplying the white matter and part of posterior horn 
of its own side. All of the arteries of the cord are 
end-arteries. 

The veins of the cord at their beginnings bear 
no relation to the arteries either in size, distribution 
or number. The greater part of the blood supply 
goes through the anterior artery, but the veins for 
the return flow are larger than the anterior arteries 
and are situated posteriorly. 



The Reflexes. 

The reflexes, whose centres are in the spinal 
cord, are the visceral and peripheral ; of the latter 
there are two kinds, the superficial or skin re- 
flexes, and the deep or tendon reflexes. In all 
cases a muscular contraction is set up by the oc- 
currence of the related sensory stimulus. It fol- 
lows that for the production of a reflex the re- 
flex loop or arc, consisting of a sensory nerve fibre, 
the connections of the same either directly or indi- 
rectly with the motor ganglion cell in the cord, the 
nerve fibre from the same and the muscle itself, must 
be intact and in physiological order. 

Of the deep reflexes, the most important is the 
patella tendon reflex or " knee-jerk." The mode of 
obtaining it is as follows : The subject being seated 
and with one knee crossed upon the other, the 
patella tendon is struck sharply with the ulnar edge 
of the examiner's hand, or with a j^ercussion ham- 
mer. The sensory impulse thereby aroused is sent to 
the cord, is passed forward, and arouses in the related 
ganglion cells of the anterior gray horn a motor impulse 
which being then sent out produces contraction of 
the quadriceps extensor muscle, causing the leg and 
foot to "kick." This reflex is believed to exist in 
all individuals in a state of health, excepting very 
young infants, and in some cases in old age. It is 
absent when any interruption of conducting power 



9 6 



THE REFLEXES. 



exists iii any division of the reflex loop, and when 
the muscle is atrophic, and thus unable to respond. 
It is prevented by abnormal conditions of the knee 
joint (anchylosis, etc.). 




Fig% 19. 

Fig. 19. — Schematic representation of the origin, course and ending of a motor 
and a sensory fibre, as also the relation of the sensory collaterals to the originating 
cells of the anterior nerve roots. The cord appears transparent. From the motor 
cell in the anterior horn a, arises the anterior root fibre b, whose ending as a small 
brush work on a striated muscle fibre is shown at c. In the posterior spinal gang- 
lion d (disproportionately enlarged) is seen a single unipolar cell, whose centrally 
directed process enters the cord as a posterior nerve root, divides at e into (f, an 
ascending, and g, a descending) main fibres, which above and below turn into the 
gray and end free, giving off on the way collaterals at h. The peripheral process 
of the posterior spinal ganglion cells passes as the sensory fibre to the periphery, 
where it ends in a naked arborization as at /, or in a complicated structure in a 
Meissner's corpuscle at k. From Lenhossek. 



THE EEFLEXES. 97 

The mechanism in the cord is, however, not inde- 
pendent. It is held in check by what is termed in- 
hibitory influence from the cortex passing downward 
in the pyramidal tracts continually. Hence, when 
from degeneration in the lateral tracts, or from brain 
disease, the inhibitory influence is obstructed in its 
downward passage or is absent, the knee jerk is 
characterized by excess in both the amplitude and 
rapidity of its motion ; it is then said to be exaggerated. 
Conditions causing exaggeration may exist with those 
for its failure, and then the knee jerk does not occur. 

Since in disease of the cerebellum and also in total 
transverse lesions in the upper dorsal region of the 
cord or higher, the knee jerk has been repeatedly ob- 
served to be lost, it has been argued that the vivifying 
influence, so to say, passes from the cerebellum to 
the centre for the knee jerk. This view has not 
received full acceptance by neurologists. 

Next to the knee jerk in importance, is the Achil- 
les tendon reflex. It is obtained by slightly pressing 
the anterior part of the foot in dorsal flexion and 
then with a percussion hammer or similar object tap- 
ping the Achilles tendon. Contraction of the calf 
muscles follows and extension of the foot upon the 
leg occurs. This reflex is believed to exist in most 
individuals, but its absence cannot be construed as 
necessarily meaning the existence of disease ; its ex- 
aggeration, however, is of the highest importance. 
When degeneration of the lateral columns has con- 
siderably advanced, the examiner finds that upon dors- 



98 THE REFLEXES. 

ally flexing the patient's foot somewhat sharply, the 
calf muscles at once contract and then yield to the 
continued extension only to immediately contract again, 
and so on as long as the pressure is kept up or until 
the muscles become fatigued. The result is a strong 
planto-dorsal oscillation of the foot at the ankle joint; 
the phenomenon is termed " ankle clonus." 

Other deep reflexes are those of the elbow and 
wrist. When the back of the radius or the back of 
the ulna is tapped near the wrist, the result is in 
many cases a reflex movement of the forearm laterally 
in the direction of the bone so tapped. Similarly, 
if the tendon of the triceps at the back of the elbow 
is tapped the partly flexed arm becomes extended. 
The absence of the arm reflexes is of no importance, 
since they cannot be elicited in all persons; their ex- 
aggeration has the same meaning as has that of the 
patella and Achilles tendon reflexes. 

Of the skin reflexes the most important is the 
cremaster reflex. It is obtained by stroking some- 
what sharply (using the back of the finger end, or 
the dull end of a paper cutter, etc.,) the inner aspect 
of the thigh. Then follows contraction of the cre- 
master of the same side, plainly drawing upward the 
testicle. The reaction is very lively in the young, 
but it may be normally absent in the old. 

The inhibitory influence is increased by the patient's 
attention being directed to the procedure. Hence, 
when the knee jerk does not appear or is very weak, 
by directing the patient to hook together the fingers 



THE REFLEXES. 99 

of the two hands and to pull hard without letting 
them part, the knee jerk will he produced if it had 
been previously over-inhibited. 

There is a false ankle clonus observed in hysterical 
conditions. It differs from the real one by the evi- 
dent existence of voluntary or intentional quality instead 
of the automatic machine-like movement characteristic 
of the real clonus. 

Other superficial reflexes are: the abdominal reflex, 
in which, when the abdomen is stroked along the 
outer edge of the rectus muscle, the muscle contracts; 
the gluteal reflex, causing distinct movement in the 
gluteal mass when the skin of one buttock is stroked; 
the pectoral or breast reflex, and the scapular reflex, 
whose names indicate their location. 

The plantar reflex is of some importance, but it 
has not been sufficiently studied. When the sole of 
the foot is tickled lightly, the foot is dorsally flexed: 
when the stimulation is strong, the leg is flexed upon 
the thigh and often the thigh upon the abdomen. 
Absence of this reflex, with exaggeration of the knee 
jerk, is taken by Dr. Buzzard as strong presumptive 
evidence of a functional disorder. 

The illustration, Fig. 20 (from Growers), shows the 
topographical relation between the spines of the ver- 
tebrae, the different emerging spinal nerve roots, and 
the location within the spinal canal of each theoretical 
segment of the cord with its nerve roots, and the 
table (from Starr and applied thus by Goldscheider) 
gives the location of the different centres, reflex, vis- 



IOO 



THE REFLEXES. 



ceral, etc., in the cord, as well as the relation of 
different levels of the cord to peripheral sensory and 
motor functions. 




Stern, mastoid. 
Trapezius 
i Diaphragm 
Serratus 



Shoulder "1 

Hand J 

' Ulnar and below. 



Intercostal 
Muscles 



Abdominal 
Muscles 



Flexors, hip 



Extensors, knee 



Abductors 



J Extensors? 



of 
hip 



Flexors of knee? 



Leg muscles for 
foot 



Perineal and anal 
muscles 



Sensory. 



Integument 
Neck and head 



Neckandshoulder 



Arm 
Hand 



Anterior side of 

thorax 
Pit of stomach 



Abdomen 
(Umbilicus) 



Posterior part : 
upper half 

Pubes and scrotum 
anterior part 
f Outer 1 

.t£ ) Anterior ( u 



* ! ii 



\< 



M 



Leg, inner pos- 
terior lower half 



Back of leg 

Limb and foot, ex- 
cept inner side 

Perineum and anus 



Integ bet. coccyx 
and anus 



Scapular refle> 



1 



Epigast. reflex 



Abdominal reflex 



Cremaster reflex 



S-Knee jerk 



Gluteal reflex 



Foot or ankle 

clonus 
Plantar reflex 



Fiff. 20. 



Diseases of the Spinal Cord. 

The diagnosis of disease of the spinal cord is 
based upon a knowledge of its anatomical structure 
and of the functions of its constituent parts. Vari- 
ations from the normal in the latter, involve the as- 
sumption of changes in the former, changes that may 
he too fine for discovery by our present methods of 
research or gross enough to be thus observed. For 
these two types of disease the terms functional and 
organic are employed, as in affections of other parts 
of the nervous system. 

An affection of the cord may be limited to a small 
part of it or may be diffusely spread through a large 
part ; hence the terms focal and diffuse. 

Disease may limit itself to certain definite structures 
of the cord, such as the posterior columns or the 
cells of the anterior gray horns ; such manifestations 
are termed system diseases. 

Disease of the cord may occur secondarily to dis- 
ease in some other portion of the nervous system, 
the disease-process simply progressing in one direction 
or the other until it finally reaches and enters the 
cord. In this manner locomotor ataxia or degeneration 
of the posterior columns has been explained as simply 
the continuation of degeneration of the posterior spinal 
nerve roots. Injury to the vertebrae, growths within 
the bony spinal canal, or haemorrhages acting by pres- 



102 DISEASES OF THE SPINAL CORD. 

sure, may destroy parts of the cord and give rise to 
extensive secondary degeneration, both upwards and 
downwards. 

The microbes (or their toxines) may be carried to 
the cord by the blood-vessels and give rise to inflam- 
matory-degenerative changes. So with many inorganic 
and organic poisons, when carried by the blood- 
vessels they exercise a specially pernicious effect on 
the cord (so-called selective action of poisons). 

Disease of the blood-vessels themselves (as in arterio- 
sclerosis, chronic alcoholism, syphilitic end-arteritis and 
peri-arteritis) by decrease of blood supply and by local 
irritation from them, can cause inflammatory-degenera- 
tive changes in the cord. 

Diagnosis of spinal cord disease is first by exclusion 
of disease of peripheral nerves on the one hand and 
of the brain on the other; secondly, determining the 
segments of the cord involved ; thirdly, determining 
the extent in cross section of the cord structures 
implicated, and finally determining the character of 
the # lesion or disease process. 

The nerve fibres forming the white matter of the 
cord have each an axis cylinder, which in turn is 
clothed with a sheath of medullary substance, but 
there is no connective tissue sheath. Herein is the 
difference between a peripheral nerve fibre and a 
spinal cord fibre. Upon the existence of the con- 
nective tissue sheath and its nuclei depend the possi- 
bility of and tendency to regeneration of the peripheral 
nerve fibre after destructive change has occurred. The 



DISEASES OF THE SPINAL CORD. 



I03 



spinal cord fibre destroyed at any part, not having a 
connective tissue sheath, cannot be regenerated, and 
the portion of the fibre not in connection with its 
originating cell undergoes secondary 
degeneration, which is permanent. The 
direction in which degeneration ad- 
vances is that of the impulses normally 
carried by the fibre. Ascending degen- 
eration, therefore, is found only in the 
posterior columns, the direct cerebellar 
tract and the antero-lateral tract ; de- 
scending degeneration is found in the 
part of the anterior column occupied by 
the direct pyramid tract and in that 
of the lateral column occupied by the 
crossed pyramid tract. 

The evidences of degeneration, as 
veS^on^si^own^n shown in properly stained and hardened 

the middle section ; below 

with s d h e° s ^end'ng SneT- sections of the cord at successive levels, 

ation in the lateral col- . , ^ 

t^'^rJc^rnllt lessen as the section is further away 

generation limited to the . . . 

posterior columns and to f r0m file Site 01 tllC OlTgllial leSlOll, 

the ascending tracts at the o " 




Fig. '21. 



lateral edge of the cord 
(direct cerebellar a 
tero-lateral tracts). 



'- owing to the turning inward into the 



gray of fibres at different levels. 

There is also a retrograde degeneration that is to- 
wards the originating cell; it is very slow in its pro- 
gress. As the fibre is already out of function it has 
no clinical bearing. 

Spinal Haemorrhage. May be outside the cord or 
within its substance. The former is divisible into 
extrameniiigeal and intrameningeal, according to the 



104 DISEASES OF THE SPINAL COED. 

position of the effusion, and most often results from 
trauma (in the new-born from injury during extraction), 
during convulsive attacks, poisoning by strychnia, 
during infectious disease. 

Symptoms resemble those of meningitis ; painful 
stiffness of the spine, radiating pains from the back 
into limbs, hyperalgesia, paresthesias, muscular rigidity. 
Later, paraplegia with anaesthesia. Small hemorrhages 
may give no symptoms, large ones are characterized by 
the sudden onset of symptoms with evidences of shock, 
the patient perhaps falling to the ground without loss 
of consciousness. The symptoms advance rapidly to 
their full height and amelioration is slow. Chronic 
meningitis may be a sequel. 

Haem atomy elia or haemorrhage within the substance 
of the cord may occur primarily from disease of the 
blood vessels or from tumors, myelitis, etc., or, second- 
arily, from trauma, excessive muscular exertion, or 
convulsions. The symptoms are paralysis of sudden 
onset, usually paraplegia, but if the lesion is high up 
the arms are paralyzed. Sensory disturbances, except 
some anaesthesia, are slight, if at all, but paralysis 
of the bladder and rectum are to be expected. Patel- 
lar reflex may be lost at first, to return later and 
become exaggerated, except when the lumbar cord 
is the seat of the haemorrhage, in which case it is 
permanently absent. 

The haemorrhage may set up a myelitis (or may be 
the result of it). 

The prognosis in both forms is serious in cases at 
all severe ; in haematomyelia the chances of restored 
integrity to the cord are but few. 



Spinal Meningitis. 

Within the spinal canal, yet ontside the proper 
structures of the cord, lesions of different kinds can 
occur. 

Haemorrhage may be extrameningeal or intramenin- 
geal ; the former is rare and occurs chiefly through 
trauma; the latter through trauma or in the course 
of spinal leptomeningitis. The symptoms in either 
case are those of meningitis, the diagnosis, when not 
evident from traumatic influence, being made from the 
suddenness of onset of the symptoms. 

Meningitis of the cord, like the meningitis of the 
brain, is divisible into pachymeningitis and leptomenin- 
gitis, according as the dura mater or the pia mater 
is the membrane chiefly or solely affected. 

Since the roots of the spinal nerves pass through 
the meninges in their course to or from the cord, 
it is evident that inflammation of the membranes must 
inevitably affect by irritation and pressure those struc- 
tures ; hence all forms of meningitis are characterized 
by certain symptoms in common, viz., eccentric or 
radiating pains from the spine, hypertonicity of muscles, 
especially those connected with the vertebras, hyper- 
algesia, paraesthesias and muscular twitchings in the 
limbs. Increasing exudation or thickening of the 
membrane may be great enough to cause paralysis 
with atrophy in one or more limbs. 

Pachymeningitis spinalis externa does not occur 



106 SPINAL MENINGITIS. 

primarily, but only from external injury or more com- 
monly from extension of disease of the vertebrae, etc. 
The symptoms already mentioned prove the involve- 
ment of the membrane, while the site of , the primary 
disease determines the course of the new symptoms. 

Pachymeningitis cervicalis hypertrophica. A special 
form of inflammation of the dura, of slow course, 
occurring in adult life and chiefly in males, in the cervi- 
cal region of the cord and usually in its lower portion. 
The causes assigned are alcoholism, injury, exposure 
to cold, and syphilis. 

Beginning as a pachymeningitis interna haemorrhagica, 
the effused blood organizes, new haemorrhages occur 
from the weak vessels of the new tissue, and this 
process being repeated from time to time, a succession 
of layers unites the dura and pia together, forming a 
dense structure constricting nerve roots and compress- 
ing the cord structures. 

The disease is divisible into three stages. First : 
the irritation of nerve roots causes pain and stiffness 
of the neck, with violent pain radiating to the occiput 
and down the spine and the arms, aggravated by motion 
and pressure ; in some instances the pains (and paraes- 
thesias) are limited to one side or nearly so. Second: 
after several months the stage of paralysis with atrophy 
begins. When the affection is in the lower part of 
the cervical cord, its manifestations are in the ulnar 
and median distribution in the arms. The unaffected 
extensors retract the hand, the fingers being flexed. 
If the meningeal thickening does not extend below 



SPINAL MENINGITIS. IO7 

the origin of the seventh cervical nerve, the ulnar 
and median distributions escape in great part, while 
the radial distribution being more greatly affected, the 
long extensors are paralyzed and there is a condition 
similar to wrist-drop. (Ross.) Third: the stage of 
spastic phenomena begins when the compression of 
the cord above has become great enough to affect the 
lateral columns. Hence the usual symptoms of spastic 
paraplegia. 

The disease may last for years, at times with periods 
of remission. The prognosis is always serious, but a 
few cures have been reported. The diagnosis, where 
the site of the disease is in the cervical enlargement, 
is not difficult, since the distribution and character 
of the pains will exclude progressive muscular atrophy, 
amyotrophic lateral sclerosis and myelitis. The his- 
tory of the case will exclude Pott's disease. When 
the symptoms are predominantly uni-lateral it may be 
difficult to exclude tumor, but in such case the lesion 
is to all intents a tumor. 

Leptomeningitis spinalis. Inflammation of the pia 
mater, as an acute disease, exists only secondarily to 
some other affection, as by extension of similar trouble 
in the membranes of the brain or by transmission of 
infectious material as in pyaemia, tuberculosis, the 
infectious diseases, of which the epidemic form of 
cerebro-spinal meningitis is one ; in the latter, in- 
stances have been reported in which only the spinal 
membrane was apparently involved. 

The disease may begin after some exposure, with 



108 SPINAL MENINGITIS. 

a chill followed by fever, pains in the back and radi- 
ating pains in the limbs, with painful stillness of the 
back and neck, rigidity of the muscles of the back 
or even opisthotonus. The pains are aggravated by 
even passive movements of the limbs, and besides ten- 
derness of the skin to touch, any pressure on the 
deeper parts is provocative of great pain. The tendon 
reflexes are exaggerated in the early stage. The 
muscles of the abdomen may be hard and contracted 
from spasm, and in some cases tightness of the chest 
amounts to dyspnoea. Similarly, from spasm, the urine 
may be retained and obstinate constipation exist. 

The disease progressing, the amount of exudation 
acts more by pressure, and paralytic symptoms ensue, 
commonly paraplegia with anaesthesia and paralytic 
symptoms on the part of bladder and rectum. 

The disease may last a few days or some weeks ; 
death may be preceded by a considerable rise in tem- 
perature and may occur from the effects of bedsores 
(sepsis) or from those of cystitis ( py elo-nephritis) or 
from exhaustion. 

The exudation is commonly purulent or sero-puru- 
lent, the membranes being bathed in it. If absorption 
take place, the membranes may be united to one 
another and to the cord, while increase of connective 
tissue with subsequent contraction may give rise to 
secondary changes in the nerve roots and the cord, 
thus producing a chronic meningo-myelitis, or menin- 
gitis alone may follow. 

The diagnosis is to be made from that of myelitis, 



SPINAL MENINGITIS. IO9 

rheumatism, tetanus and meningeal haemorrhage. In a 
pure myelitis there is little or no pain and the para- 
lytic symptoms predominate ; in rheumatism there are 
no radiating pains and no spasm of distant muscles ; 
in tetanus the early appearance and prominence of 
trismus, as well as the absence of increased temper- 
ature, are decisive ; with meningeal haemorrhage there 
are radiating pains, but they appear with great sudden- 
ness and violence. 

The prognosis in internal spinal meningitis is always 
grave ; the higher the fever, the earlier paralysis sets 
in ; and the more severe the pains, the worse is the 
outlook. So in tubercular cases the prognosis is worse 
than in rheumatic ones and better in traumatic cases 
than in those arising without known cause. 

Treatment. Absolute rest in bed must be enjoined 
with freedom from external irritation of all kinds, even 
including light and noise. In traumatic cases the well- 
known remedies, Arnica, Hypericum perforatum, Rhus 
toxicodendron; in cases following exposure to cold or 
wet, Rhus toxicodendron, Dulcamara, Bell is perennis, 
will be thought of, the selection to be made according 
to the special symptoms in any one case. Belladonna, 
Bryonia alba, Cicuta virosa, Xux vomica, Mercurius, 
Physostigma venenosa and Iodoformum should be studied. 

Iodoform has repeatedly caused cerebral meningitis 
when absorbed from wounds, and its use in the 6th 
dilution by the writer has more than once been re- 
markably helpful in that form ; hence it is advised in 
the spinal form. 



110 SPINAL MENINGITIS. 



Chronic Spinal Meningitis. A chronic idiopathic 
leptomeningitis spinalis is an extreme rarity, if it 
exist at all. 

As the final stage of acnte spinal meningitis, or 
as secondary to syphilis or alcoholism or injury it 
is not unknown. Its symptoms are those of the 
acute form, but in less severity, and the anatomico- 
pathological changes in the membranes are increased 
connective tissue proliferation, causing adhesion of pia 
and arachnoid, with thickening and opacity. There 
may be adhesion to the cord causing compression 
and inflammation of its circumferential edge. 

When the affection is the result of the syphilitic 
processes, the more characteristic signs are stages of 
advance and regression of the symptoms ; the in- 
completeness of the phenomena and the extensive- 
ness of the manifestations would give strong pre- 
sumptive evidence of such cause even without satis- 
factory history. 

Treatment. If the case is believed to be syph- 
ilitic, Sypliilinum, high, may be given, or Mercurius, 
Auram muriaticum natronatum or Nitric acid, all low, 
may be used. In non-syphilitic cases the great an- 
tipsorics, Sulphur, Calcarea carbonica, Lycopodium clav- 
atum and Silicea ought to be held in mind. Iodo- 
form 6 has been of such signal value in meningitis 
that even in old cases, where it has not been used, 
its employment should not be omitted. 



Myelitis. 

The word myelitis means an inflammation of the 
spinal cord, and, strictly speaking, might be applied 
to any inflammation of any part of that structure. 
Its use, however, without any qualifying word, is 
commonly held to apply to inflammatory processes ex- 
tending diffusely through the cord transversely. It 
may include the whole cross-area of the cord, or only 
a part; it may extend longitudinally through many 
segments of the cord, or include only one. More 
than one focus of inflammation may exist at the same 
time. 

The anatomical changes resulting from the myelitic 
process are softened consistency of the cord, loss 
of difference in tint between the white and gray 
matter, while under the microscope are seen in- 
creased vascularity, the vessels being surrounded by 
leucocytes, swelling of the axis cylinders and of the 
myeline, and swollen and deformed nerve cells. In 
a late stage there are evidences of degeneration of 
the myeline, aggregations of granular corpuscles and 
of fat granules, and still later, proliferation of the 
neuroglia, leading to a final stage of connective tissue 
formation, with disappearance in great part of all 
nervous elements. 

At present the process is held to be dependent 
upon infection, at least in the majority of cases, 
but exposure to cold and wet, traumatism, etc., 



I I 2 MYELITIS. 

cannot be denied as occasional causes. The infec- 
tious diseases, syphilis, gonorrhoea and septic pro- 
cesses are the chief excitants. 

The symptoms of myelitis are those of interference 
with, or loss of function in, the different structures of 
the cord and vary with the varying height and ex- 
tension of the inflammatory process, and its varying 
intensity in the cross section of the cord. 

The typical form is a transverse myelitis, and the 
most common site is the dorsal cord. 

Symptoms. A prodromal period of some sensory 
disturbance, limited to slight paraesthesia or pain in 
the related limbs, is followed by weakness or heavi- 
ness in the legs that soon becomes paralysis, and 
anaesthesia for all kinds of sensation, the sensory loss 
extending upon the trunk as high as the nerve dis- 
tribution from the upper limit of the disease in the 
cord. Just above this limit there is irritation and 
consequent hyperaesthesia upon the trunk, and at its 
junction with the anaesthesia is felt the very com- 
mon girdle sensation. 

With the paraplegia are associated stiffness of the 
legs and increase of the tendon reflexes, while later, 
spasms or more prolonged flexor contractions in the 
lower limbs may occur. If the disease is intense in 
quality and involves the whole cross section of the 
cord in the upper dorsal region or higher, the tendon 
reflexes are abolished in many cases (Bastian, Bruns). 

Paralysis of bladder and rectum are partly due to 
anaesthesia, partly to interference with the voluntary 



MYELITIS. 1 1 3 

control. In the early stage the bladder requires the 
use of the catheter ; later there is incontinence for 
both viscera. 

Trophic changes may be found even early, due 
to the influence of uncleanliness and the lessened 
resisting power of the skin; bed-sores result at 
points most under pressure, such as the sacrum, 
trochanters or heels, and carry with them the danger 
of septic infection. 

Cervical myelitis. The symptoms already described 
are present, with the difference that the higher site 
of the trouble in the cord causes a higher limit (on 
the periphery) to the anaesthesia and the girdle sen- 
sation, and gives rise to paralysis in the arms, usually 
with some amount of degenerative atrophy. Dyspnoeic 
conditions may be present from implication of the 
respiratory muscles. 

Lumbar myelitis. When the lumbar enlargement 
of the cord is the site of the lesion the symptoms 
are different. The paralysis of the lower limbs is 
degenerative, the tendon reflexes are weakened or 
lost, anaesthesia may not extend higher than the in- 
guinal regions, and paralysis of bladder and rectum 
are very pronounced. The skin reflexes are lessened 
or absent. 

In myelitis of any region of the cord vaso-motor 
changes may occur; cyanosis and oedema of the 
paralyzed limbs are not infrequent. 

The course of an acute myelitis is rather rapid, 
so that in a few days, or perhaps a week, the 



114 MYELITIS. 

symptoms have fully developed, witli some increase 
of temperature ; then follows a stationary period last- 
ing some weeks or some months, and from this the 
disease may regress to cure or to improvement only, 
or advance to a fatal ending, or to a stage of 
chronic myelitis, with more or less permanent reten- 
tion of many of the foregoing symptoms. 

The prognosis is always doubtful, but is more favor- 
able when the disease follows one of the acute infectious 
diseases ; when occurring during the puerperal state, 
or during tuberculosis, or from sepsis the prognosis 
is bad. The presence of radiating pains is considered 
by Oppenheim of good augury, in doubtful cases, 
while the early appearance of bed sores, or of com- 
plete paralysis of bladder and rectum are evil omens. 

Chronic myelitis, except as the outcome of the 
acute form of the disease, is uncommon. The diag- 
nosis must be made by the symptoms already de- 
scribed appearing slowly and with less intensity. 

Syphilis of the Spinal Cord. That syphilis is often 
a prominent factor in the etiology of myelitis cannot 
at present be doubted, but as the disease process 
only affects the cord by way of the pia and arach- 
noid, the result is more properly a meningo-myelitis 
syphilitica. The anatomical changes seen in the 
meninges at the autopsy may, indeed, be slight, 
while the cord structures are severely affected and 
present the appearances of a diffuse or disseminated 
myelitis ; in other cases the cord is involved only at 
its periphery (in cross section). 



MYELITIS. I I 5 

The blood vessels are both starting points and 
channels for extending the disease process, and not 
only endarteritis, but even obliterating phlebitis may 
be present. 

The manifestation of the disease may occur within 
a year after infection, oftener within the first six 
years. 

The symptoms vary, as in all diseases of the cord 
or meninges, according to the height of the diseased 
segments, and the extent of the process in cross 
section. Symptoms of irritation and compression of 
the nerve roots are radiating neuralgic pains in back 
and extremities, girdle pain, anaesthesia and parses- 
thesia and, if the cervical or lumbar enlargement is 
specially affected, atrophic paralysis in arms or legs, 
limited to single muscles or groups of muscles, may 
be expected. From the implication of the cord struc- 
tures paraplegia occurs, often with predominance of the 
paretic state in one limb, or a Brown-Sequard's pa- 
ralysis, with loss of control of the sj^hincters. 

More characteristic of the syphilitic process is the 
variability of the symptoms from time to time, or 
at times from day to day, even the tendon reflexes par- 
taking of this. 

In some cases there is a marked spastic gait, with 
exaggeration of the knee jerks, yet without great in- 
crease of muscular tonus. As sensation is in these 
cases (called by Erb syphilitic spinal paralysis) but 
slightly impaired, it may be assumed that the brunt 
of the attack is borne by the cord itself. 



I 1 6 MYELITIS. 

Compression Myelitis. Compression of the cord 
can occur as a result of meningeal thickening (q. v.), 
haemorrhage within the spinal canal (q. v.) of tumors, 
in the ordinary sense, growing within the vertebral 
canal and of deformity of the spinal column, most often 
as a result of tuberculosis or caries of some of the 
vertebrae (Pott's disease). 

In the process the bodies of some of the vertebrae 
are changed, softened and disappear, with consequent 
falling together of the less affected vertebrae above 
and below, causing angular projection of the 
spinous processes of the diseased vertebrae. The in- 
cluded cord is of course bent and stretched and also 
exposed to pressure. Additional pressure will follow 
if the disease involve the periosteum, or cheesy pus 
accumulate beneath the latter (sometimes for several 
inches). In other cases formation of pus may be ex- 
tensive upon the dura mater, causing additional com- 
pression. 

The symptoms are of two kinds : those of the 
vertebral disease and those of the spinal cord and 
nerve roots. The former are stiffness of the spine, 
pain on movement, tenderness of certain vertebrae to 
pressure (a symptom to be accepted with great caution, 
as it is found in neurasthenia) and protrusion of some 
of the spinous processes. Even the latter is not to 
be taken as evidence of vertebral disease, for Charcot 
has shown (Iconographie de la Salpe'triere, Vol. I.) 
photographs of the ancient Greek statues of athletes 
having marked projection of the vertebral spines in 



MYELITIS. I I 7 

the lumbo-dorsal region. The writer holds this to 
be due to slight displacement backward of the pro- 
jecting vertebrae, and has seen it after severe work 
and in some cases of neurasthenia. 

An angular protrusion is different, and may be ac- 
cepted as diagnostic of disease of the bodies of the 
affected vertebrae. 

The vertebral symptoms may exist for a long time 
without attracting much attention. 

The first spinal symptoms are usually painful sen- 
sations radiating along the course of certain spinal 
nerves, whose roots are in the extent of the lesion, 
and they vary according to its site. If the cervical 
vertebrae be affected the pains are in the shoulders 
and arms ; if in the dorsal vertebrae there is a girdle 
pain. The pains are mostly neuralgic in character, 
but at times are dull, drawing. 

The tendon reflexes whose reflex loops are below 
the site of the disease process are always increased. 

Next, weakness and stiffness of the lower limbs 
appear, the weakness gradually increasing until com- 
plete paralysis results. These symptoms may begin 
in one leg, to appear later in the other, or may pre- 
dominate in one. The seat of the affection is in the 
majority of cases in the dorsal vertebrae; when in the 
cervical vertebrae the arms are affected first and the 
lower limbs only later in the course of the disease. 

In many cases the spastic paraplegia, with rigidity 
of legs, ankle clonus, etc., are present, due to the 
interference by compression with the passage of in- 



I I 8 MYELITIS. 

hibitory impulses down the cord. In some cases the 
paralysis of the lower limbs is a lax one. 

Sensory disturbances, besides the pains already 
mentioned, are limited to some anaesthesia and pares- 
thesia. Bladder and rectum are affected in nearly all 
severe cases of compression of the cord, in the early 
stages retention of urine appearing, in the later stages 
incontinence. 

In the few cases in which the lumbar vertebrae 
are the seat of the disease there will be atrophy of 
the related muscles with reaction of degeneration. 

The disease is almost always chronic in its course, 
and the vertebral affection may exist for months and 
even for years before the spinal symptoms appear. 
Sometimes the spinal symptoms give the first clue to 
the existence of disease of the vertebrae ; often both 
sets of symptoms appear about the same time and in 
some cases the deformity of the spinal column is 
absent. 

The further course of the disease is protracted, 
often with periods of apparent cessation or even of 
temporary relief of the paralysis. 

The majority of cases die, bedsores, cystitis and 
pyelonephritis, septicaemia or general tuberculosis being 
agents in the fatal ending. The prognosis is much 
more unfavorable when the bone affection includes 
either the lumbar or cervical enlargement of the cord, 
or when it appears in the adult, or when evidences 
of general tuberculosis are present. 

Diagnosis. First, from the symptoms already given, 



MYELITIS. I 1 1 



diagnosis of pressure upon the cord in some definite 
portion must be made. Next in order is the diagnosis 
of the character of the latter. Pott's disease appears 
in young life, although it may come at any age. Car- 
cinoma of the vertebrae appears for the most part after 
the 40th year. In the one case there often are signs 
of tuberculosis, in the other the existence of carcinoma 
elsewhere would be a guiding point. In Pott's disease 
the kyphosis is as a rule angular; in carcinoma the 
deformity is a protuberance not angular and less in 
size than in the other condition. In carcinoma of 
the vertebrae the initial sensory symptoms are of 
great intensity, so that the term paraplegia dolorosa 
is used to designate the extremely painful condition 
found in compression of the cord, due to this cause. 

Pathological anatomy. Post mortem, the cord when 
taken out is noticed to be softer than normal in the 
compressed portion, is smaller and sometimes even 
appears constricted. There is no real inflammation, 
so that the term myelitis is incorrectly applied to the 
condition present. Microscopically, a number of the 
nerve fibres are destroyed, many are in the process 
of degeneration, with swollen axis cylinders already 
deprived of their myelin e sheath. Later comes pro- 
liferation of glia tissue, and subsequently a sclerosed 
area. 

The diagnosis of myelitis will depend upon the 
existence of paraplegia, stiffness of the limbs, exag- 
geration of the tendon reflexes (occasional loss of 
knee jerks in a total transverse myelitis high up in 



120 MYELITIS. 



the cord), anaesthesia in the paralyzed parts, girdle 
sensation at the npper limit of anaesthesia, paralysis 
or paresis of bladder and rectum, the occurrence ot 
bed-sores. Meningitis is characterized by pain and 
superficial tenderness of limbs without bladder symp- 
toms; multiple neuritis, by pain along the nerve trunks 
and no bladder trouble. Landry's paralysis of central 
type is a rapidly ascending disease of the cord. 

The hygienic treatment of myelitis consists of 
measures to prevent, if possible, the formation of 
bed-sores, or the occurrence of cystitis. For the first 
the patient should be often examined in the parts 
exposed to pressure, and these should be bathed in 
alcohol and water, while the bed clothing should be 
scrupulously clean. If there is paralytic retention of 
urine, the catheter must be used only after extreme 
aseptic precautions; if there is incontinence, a suitable 
urinal should be kept always in place. The bowels 
should be relieved by the aid of plain enemata. 

Of the remedies to be prescribed, those having 
causal indications should be used first. For traumatic 
cases, Arnica, Bellis perennis and Bhus toxicodendron; 
for cases following exposure to dampness or wet 
cold, Dulcamara, Bhus toxicodendron, Bellis perennis. 
A cause should always be looked for. . When none 
of the foregoing is found, the existence of some in- 
fectious disease (or a wound) may give a clue to an 
effective remedy. If syphilis has existed, and no 
other cause is assignable, Mercurius iodatus flavus, 
or solubilis, may be prescribed, or the isopathic prin- 



MYELITIS. I 2 1 

ciple may be employed by prescribing Syphilinum 
200th or higher. Similarly, if gonorrhoea has pre- 
ceded the disease. Many substances, metallic, vege- 
table or animal in origin, have caused experimentally, 
myelitis (Bruns) in the lower animals, but our prov- 
ings have not been carried to such extent on the 
human subject. Nevertheless many of our drugs have 
among their symptoms those strongly characteristic 
of the disease. The symptoms that are diagnostic 
are not, as we learn from Hahnemann, the ones lead- 
ing to the selection of a remedy, but rather those 
that are striking and peculiar, together with the ag- 
gravations and ameliorations. 

In the early stage, Aconite, Belladonna, Gelsemium, 
Veratrum viricle ; when any fever has lessened, Arsen- 
icum, the metals, especially Mercurius, Cadmium and 
Plumbum. Oxalic acid, Secale and Phosphorus may be 
studied. 

In the chronic condition, besides the remedies men- 
tioned, Beroeris vulgaris when the bladder symptoms are 
marked, JEscidus hippocastanum when rectal, sacral or 
perineal symptoms are prominent, Picricum acidum 
when the genito-spinal centre is irritated. In old 
cases, with marked spastic symptoms, Lathyrus sativus 
has been of great service. 

Cases of myelitis uncomplicated with meningeal in- 
volvement are not common, and the reader is referred 
for additional remedies to the section on spinal men- 
ingitis. 



System Diseases of the Spinal Cord. 

Certain systems of fibres, or of cells, may be at- 
tacked by certain degenerative disease processes to 
the exclusion, or nearly so, of all other parts of the 
cord. The term does not include processes of de- 
generation following and resulting from a lesion in 
some part of a system, such, for instance, as the 
secondary degeneration of a lateral column after 
haemorrhage in the cerebral motor tract. 

Poliomyelitis anterior acuta. This disease is pre- 
dominantly one of early childhood, most of the cases 
appearing during the first, second and third years, 
while after the fifth year cases are few, although the 
disease may occur in the adult. 

It is an infectious disease, appearing sometimes as 
an epidemic in small areas of country, but its special 
microbe is as yet unknown. It also occurs after 
other infectious diseases, such as scarlatina, measles 
and whooping cough. 

Symptoms. The outbreak of the affection is like 
that of any acute infectious disease. The patient is 
taken, usually while in good health, with high fever, 
headache, some pains in the limbs, vomiting at times, 
and may become delirious or stupid, and in some in- 
stances will have general convulsions. These acute 
symptoms last from a few hours to a day or two, 
but occasionally may continue a week or so. 



SYSTEM DISEASES OF THE SPINAL COED. I 23 

At the end of the acute stage it is noticed that 
the child is paralyzed, the paralysis being wide- 
spread and, perhaps, involving all four extremities, the 
trunk muscles and the bladder. A slowly progressive 
improvement soon sets in, and whole limbs may be 
restored to full power and activity, or many groups 
of muscles regain their function. This process may 
continue for several weeks, or for some months, and 
then it stops, and the patient is left with paralysis 
of certain groups of muscles, most frequently in one 
leg, very often in both, less often in an arm, or in 
an arm and leg. 

The paralysis is a lax one, with loss of the 
tendon reflexes of the muscles involved, and with 
atrophy and reaction of degeneration. 

The muscles most commonly left in this state 
are, in the leg, those on the extensor side, the anterior 
tibial, the common extensors and the external peroneal; 
any one of these or any two or all three may be 
affected. In the thigh, the quadriceps extensor and 
the inward rotators are often the ones chiefly paralyzed; 
in the forearm, the extensors ; in the arm, the deltoid 
and flexors. I have seen one case in which the calf 
muscles were completely atrophied. 

Sensibility is at no time altered, nor is any pain 
present, except some tenderness of muscles during the 
process of atrophy. 

Owing to the unopposed action of unaffected muscles, 
various deformities arise, talipes equino-varus, talipes 
valgus, flexor contraction at the knee, and some lateral 



I 24 SYSTEM DISEASES OF THE SPINAL CORD. 

curvature of the spine being those most frequently 
seen. 

Pathologically, the disease is a myelitis limited to 
the anterior gray horns of the cord, with destruction 
of some of the motor cells. As a cell once destroyed 
cannot be reproduced, it follows from the regression 
of the paralysis that many of the cells have not lost 
their integrity ; and cases of paralysis, from the disease 
under consideration, existing for some years, have 
shown very great improvement as soon as treatment 
was begun, which continued until the limb or limbs 
were practically restored to usefulness. 

The nutrition of a limb severely affected is 
lowered and its rate of growth retarded. Hence, in 
cases of long standing, the bones are smaller than 
normal in all directions and the member is shorter, 
while the skin is cyanotic and cooler than that of its 
healthy fellow. 

The diagnosis in the acute stage cannot be made, 
except in the presence of an epidemic of the disease. 
When the paralysis is first observed, if convulsions 
have preceded it, the physician may think of cerebral 
infantile paralysis ; but in poliomyelitis the loss of the 
tendon reflexes would resolve all doubt. From multiple 
neuritis the absence of pain or of tenderness along the 
nerve trunks, and the fact that multiple neuritis is 
extremely rare in children, would be sufficient for 
differentiation. 

The chronic form of poliomyelitis anterior is a 
rarely observed disease. It begins with weakness of 



SYSTEM DISEASES OF THE SPINAL CORD. I 25 

one limb, which gradually increases until the use of the 
member is seriously impaired. Xext, the fellow mem- 
ber is attacked, and still later, the other limbs ; and in 
the course of several months there may be incomplete 
paralysis of all. The paralysis is a lax one, and upon 
testing there will be found degenerative atrophy of 
certain groups of muscles, just as in the acute form. 
Sensation is not impaired, but there may be slight 
rheumatic pains. Fibrillary contractions in the degen- 
erating muscles are almost always present. The 
sphincters are not affected. 

The disease process, after having gone on for several 
months, may stop and a process of restoration set in 
that at times becomes complete. In other cases there 
is a steady advance of the trouble until all the muscles 
of the limbs, as well as some of the trunk, are wasted, 
and the patient is bed-ridden. Death occurs in from 
one to three years, usually from implication of the 
respiratory muscles, when pneumonia (from the inva- 
sion of the larynx and bronchi by food) or even a 
slight bronchitis, is sufficient to cause a lethal ending. 

Diagnosis. From progressive muscular atrophy of 
spinal origin the disease is differentiated by the fact 
that weakness and paralysis precede the atrophy, and 
that the progress of the disorder is here rapid. 

The treatment of poliomyelitis anterior in the acute 
stage must be purely systematic, as in the case of 
any infectious fever of childhood; but when the 
acute symptoms have passed off and the paralyzed 
condition of the limbs is recognized, Plumbum should 



I 26 SYSTEM DISEASES OF THE SPINAL COED. 

be given in a moderate dilution. This metal has 
caused degeneration of the cells in the anterior gray 
horns of the cord, and the earlier the diagnosis the 
sooner the remedy can be prescribed. After the 
active process has ceased in the cord, restoration of 
cells not destroyed takes place to a considerable 
degree, and it is fair to assume that an early use 
of so homoeopathic a remedy as lead is, will be of 
great value. This remedy is of undoubted service 
in cases of old standing paralyses from a previous 
poliomyelitis. The writer gives it in 30th potency, a 
dose every night for a week, intermits for a week 
and resumes— and so on. If other remedies are in- 
dicated, they should be given from time to time. 

Goldscheider has shown that the trophic influences 
governing the peripheral parts are kept active by 
the stimulus of centripetal impulses from the per- 
iphery. Hence, the undoubted value of massage, of 
" salt rubbings," etc., in this paralysis. But greatest 
of all is the systematic use of galvanism to the af- 
fected muscles. The anode is to be used with an 
interrupting handle, and a current strong enough to 
cause contraction in the muscle is to be passed and 
then broken, making interruptions and contractions of 
the muscles about twice in a second, twenty-five or 
thirty times. Another muscle or set of muscles is 
then treated, and so on until all the paralyzed 
muscles have been thus exercised. The other pole, 
cathode, is to be kept on some indifferent part, and 
possibly with advantage over the spine above the 



SYSTEM DISEASES OF THE SPINAL CORD. I 27 

site of the cord lesion. This should be a large flat 
electrode. The current required to cause contraction 
may be so great that the pain cannot be borne, in 
which case by employing a non-interrupting handle 
the anode may be used labile, up and down the af- 
fected muscles for three or four minutes each, the 
current strength to be moderate, 6 to 8 m-a. The 
treatment should be given every other day for a 
period of 5 or 6 weeks, and then intermitted for a 
week or two, to be resumed for another period of 5 
or 6 weeks. Contractures and deformities may, in 
the young, be prevented or lessened by orthopaedic 
mechanical devices. 

Primary Degeneration of the Motor Path Under 
this term Mobius makes a bold generalization and 
includes the diseases known as spinal progressive 
muscular atrophy, progressive bulbar paralysis, and 
amyotrophic lateral sclerosis. Charcot had given to 
the latter form its place as a distinct type of disease, 
while Growers in his consideration of chronic muscular 
atrophy (text book) says he has not yet met with a 
single case of progressive muscular atrophy in which 
the pyramidal tracts were not affected, and in another 
part of the same chapter he states: " Atonic muscular 
atrophy is, at least in many cases, the visible expression 
of a tendency to decay of the whole motor path, from 
the cortex of the brain to the muscles.' 1 

Since in both of these forms of disease the symp- 
toms of progressive bulbar paralysis often appear, and 
since the cranial nerve nuclei in the medulla are con- 



128 SYSTEM DISEASES OF THE SPINAL CORD. 

sidered as the analogues of the groups of ganglion 
cells in the anterior gray horns of the cord, the gener- 
alization of Mobius need not be considered strained, 
and it is of value in giving a readier insight into the 
features of the three forms. 

Mobius says that a primary degeneration of the 
motor tract may exist throughout its whole extent, 
from its beginning in the cells of the central convolu- 
tions of the cortex to its ending at the ganglion cells 
in the anterior gray horn of the cord ; that it may 
involve only the fibres of the tract in their spinal 
extent and the anterior horns ; and, finally, that it 
may affect the anterior horns alone. Destruction of 
the cells here of course involves destruction of the 
rest of the peripheral neurones and the muscle fibres to 
which they are distributed. The same author doubts 
the existence of a primary degeneration limited to 
the lateral columns, that is to say, without implication 
of the cells of the anterior horns. 

The anatomical changes are always the same : the 
cells become shriveled in appearance, they break up 
and disappear, as do the axis cylinders, the medullary 
sheaths being seen in all stages of degeneration ; slight 
secondary proliferation of the glia, slight changes in 
the blood-vessels, shrinking of the muscle fibres, with 
fatty or waxy degeneration and fissuration in them, 
and increase of connective tissue or of fat amid them, 
and increase of the muscle nuclei, are later changes. 

The cause of the disease is unknown, but Mobius 
thinks that congenital weakness in the neuro-muscular 



SYSTEM DISEASES OF THE SPINAL CORD. 1 29 

apparatus is a fair presumption ; it begins in the adult 
as a rule while in good health and is not found in 
several members of a family. 

Spinal progressive muscular atrophy begins usually 
in one upper limb, more often the right. In the 
majority of cases, weakness and wasting are noted 
first in the muscles of the ball of the thumb, in some 
instances preceded by slight rheumatic pains or numb- 
ness. Soon other muscles become affected and the 
eminence at the ulnar side of the palm or the inter- 
ossei and lumbricales gradually disappear. Next, in 
most cases, the muscles of the forearm are involved, 
but in some instances they escape for a time, the 
deltoid and other muscles about the shoulder being 
attacked instead. Occasionally, the atrophy begins in 
the shoulder muscles. 

After the disease has progressed to some extent, 
the other side is affected, but not necessarily in the 
same order. 

When the wasting in the interossei and lumbricales 
is pronounced, and the extensors and flexors of the 
forearm are still intact, the hand assumes the much 
pictured "claw hand" type; in other cases the un- 
opposed action of the long extensor of the metacarpal 
bone of the thumb brings that member up to the level 
of the other metacarpal bones and gives rise to what 
is known as the "ape hand." 

After the deltoid, the triceps and biceps and supra 
and infra- spinat us are involved in varying order, fol- 
lowed by the trapezius, rhomboid, pectoral, serratus 



I30 SYSTEM DISEASES OF THE SPINAL CORD. 

and other deep muscles of back. The muscles of 
back of the neck may be affected so that it is difficult 
to erect the head upon the spine. The intercostals 
suffer in some cases ; in others the diaphragm — in 
either case respiration is abnormally performed. 

The lower limbs are not affected until late in the 
disease, and usually not so severely as the upper ones. 

During the process of wasting the muscles show 
certain symptoms, not, however, characteristic of the 
disease, but rather of atrophic degeneration. Fibrillary 
contractions or " flickering," to use Gowers' term, in 
parts of a muscle, are quite common. The electrical 
reactions vary according to the rapidity of the wasting 
as well as its degree, so that the electrical con- 
tractility may be only lessened or it may be extin- 
guished ; where there is some amount of paralysis 
preceding atrophy, as occurs in some parts (Gowers) 
there may be the typical reaction of degeneration ; 
in other parts there may be partial reaction of degen- 
eration. The tendon reflexes disappear as soon as 
the related muscles become even slightly affected. 
Bladder and rectum are not involved, but sexual power 
is often lost. 

The progress of the disease is usually a steady one, 
at times with apparent cessation, and Gowers holds 
that when once actually arrested, it does not usually 
again become active. Its duration may be a few years 
or many. Death occurs, commonly, from some inter- 
current pulmonary disorder or from the invasion of 
the medulla by the disease process, which, indeed, is 



SYSTEM DISEASES OF THE SPINAL CORD. I 3 I 

the most frequent "complication," and will be described 

under diseases of the brain-axis. 

Amyotrophic Lateral Sclerosis. It may be accepted 
that in the great majority of cases of spinal progressive 
muscular atrophy, the lateral pyramidal tracts in the 
cord are also degenerated, and that the usual clinical 
evidence of the latter process is not present, because 
in all cases the ganglion cells are so extensively in- 
volved that the resulting widespread atrophy of muscle 
renders spastic symptoms with exaggeration of the 
tendon reflexes impossible. In some cases, the damage 
to the ganglion cells not being so extensive, the symp- 
toms cine to disease of the lateral columns do appear, 
and then to the syndrome the term amyotrophic lateral 
sclerosis is applied. 

The symptoms begin in the same way as in the 
previously described form, by gradual spread of atrophy 
in the small muscles of one hand, but in the muscles 
not affected there is hypertonicity with active tendon 
reflexes, the knee-jerks even at this early period often 
being exaggerated. Alter several months the patient 
complains of weakness in the legs, and soon the 
typical spastic gait with weakness of legs and marked 
increase of the knee jerk and often ankle clonus, with 
absence of pain or sensory disturbance and of bladder 
or rectal trouble, prove plainly enough the existence 
of degeneration of the lateral columns. The patient 
can walk until a late period in the disease, but the 
weakness and stiifness of the legs make walking an 
effort. The last stage of the disease is the appearance 



132 SYSTEM DISEASES OF THE SPINAL COED. 

of bulbar symptoms. Death occurs from some inter- 
current affection, mostly of the respiratory organs, or 
from cardiac or respiratory paralysis, due to the bulbar 
involvement. 

The diagnosis of spinal progressive muscular atrophy 
is not difficult. By the inexperienced it may be con- 
founded with one of the muscular dystrophies. But 
the beginning of the trouble usually in the small 
muscles of one hand, the age of the patient at the 
time of its first observed symptoms, the absence of 
similar cases in the same family, the presence of 
fibrillary contractions and in some muscles of the re- 
action of degeneration, give the stamp of authenticity 
to the diagnosis. 

Chronic poliomyelitis anterior attacks several limbs, 
the atrophy is preceded by paralysis, the reaction of 
degeneration is present in the affected muscles, the 
progress is relatively rapid up to a certain point, when 
it ceases and improvement results, or else it advances 
in a way not to be distinguished from progressive mus- 
cular atrophy. 

The absence of pain or of other sensory disturbances 
will distinguish progressive muscular atrophy from 
syringomyelia, pachymeningitis cervicalis hypertrophica 
and caries of the lower cervical vertebrae. 

In the atrophy following lead poisoning there is no 
advance in progress after the cause has been removed, 
while the history and concomitant symptoms will de- 
cide before- such cessation occurs. Amyotrophic lateral 
sclerosis is readily recognized by its symptoms already 



SYSTEM DISEASES OF THE SPINAL CORD. I 33 

described, and the differential diagnoses just given will 
apply here. In both forms the occurrence of bulbar 
degenerative changes are to be expected, and this 
may lead to confounding the disease with disseminated 
sclerosis. 

If the views of Mbbius that progressive muscular 
atrophy and amyotrophic lateral sclerosis are but the 
manifestation of congenital fault in the structures of 
the motor paths, be correct, the problem of treatment 
becomes more complicated. Goldscheider's view that 
trophic influence is aroused and kept active by peri- 
pheral sensory impressions is widely accepted, but if 
the cells themselves (motor neurones) are imperfect, 
increased peripheral stimulation ought to wear them 
out the sooner. Nevertheless, the writer has seen the 
most remarkable results, amounting to arrest of the 
atrophy, in more than one case under the use of 
taradism to the affected region and of Phosphorus 6 
internally, continued for some months ; and that method 
is here recommended in the spinal type of progres- 
sive muscular atrophy. Other remedies, such as 
Plumbum metallicum, Cuprum metatticum and Zincum 
metallicum may be better indicated in individual 
cases, and different observers have used Arsenicum, 
Picrkum aeidum, Argentum nitrieum, Physostigma vene- 
nosa, Belladonna and Xux vomica. The value of the 
deep acting antipsoric remedies in constitutional con- 
ditions mav be tested here. 



134 SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. 



Locomotor Ataxia. 

Tabes Dorsalis. This disease, of frequent occur- 
rence, is, except in a few atypical cases, the easiest 
of diagnosis among all the organic affections of the 
nervous system. 

Its appearance depends upon the existence of a 
previous syphilitic infection, or at least Erb's statistics 
show that in but five per cent, of his cases could a 
23receding syphilis be fairly excluded. 

As the anatomical changes occurring in the progress 
of the disorder entirely differ from those of the syphil- 
itic process, it is assumed that the latter leaves behind 
it a toxine having a specially injurious affinity, under 
certain exciting causes, for certain nervous structures. 

The exciting causes are physical overexertion, ex- 
posure to wet and cold, an immediately preceding 
attack of some acute infectious disease, "fast" living 
and other weakening influences. 

From a series of 600 cases of the disorder in Erb's 
private practice, Leimbach (Deutsche Zeitsch. f. 
X'h'kunde, Bd. 7, Hft. 5 u. 6) has selected 400 in 
which the records were exceptionally complete in de- 
tails. The first symptom most frequently observed was 
the lightning pains which occurred as such in 277 
cases in the legs, in 5 in the back, and in 1 in the 



SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. I 35 

arms. In 62 cases the lightning pains did not appear 
as the first symptom, and in 11 cases only as the 
third, while in 47 cases they did not occur throughout 
the whole course of the disease, but 100 of the ob- 
served cases were examined in the early stage of the 
disorder. 

A feeling of weakness in the legs and of too readily 
occurring fatigue as noted as the first symptom in 
78 cases, as the second symptom in 113, as third in 
44, and as fourth in 11. Leimbach considers this, 
although appearing in many nervous affections, as of 
great diagnostic value, especially as an early or initial 
symptom. 

Loss of the knee jerk and of the Achilles tendon 
reflex is the most constant symptom in tabes, yet in 
3.75 per cent, of the 400 cases the reflexes in the 
lower limbs were normal, but the percentage of such 
exceptions will undoubtedly be lessened as time ad- 
vances in the 100 cases in the early stage. 

Paresthesias in legs and feet have a high rank as 
the initial symptom ; they occurred as such in 74 
cases, as the second symptom in 110, and as third 
in 55. 

The disease is predominantly one of middle life, 
being most common from 30 to 50, and this because 
the syphilitic infection occurs most frequently between 
the 20th and 40th years, the interval elapsing between 
infection and the appearance of the disease being 
usually something less than ten years, although it has 
followed within two years and been delayed 15 or 20. 



136 SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. 

Its occurrence in childhood is denied by Oppenheim, 
but it may develop as late as the sixtieth year.* 

Men are much more frequently affected than women. 

The disease is divisible into three stages : the pre- 
ataxic, the ataxic, and the paralytic. The first is 
manifested most commonly as sensory disturbances, 
consisting of severe sharp pains, lancinating and light- 
ning-like, shooting down the lower limbs, or limited 
to small areas, and often mistaken for rheumatic pains. 
In some cases these are boring or constricting or 
burning. They appear in attacks lasting from a few 
hours to a day or two, and are often intolerable in 
severity ; the intervals of freedom from pain are in- 
definite in length. 

A symptom of great diagnostic importance and 
which appears early in the great majority of cases, is 
loss of the reflex contraction of the pupil to light, 
while the associated contraction in convergence is re- 
tained. This manifestation is known as the Argyll- 
Robertson pupil. In testing the response of the pupil 
under the retinal stimulus by light, it is important 
that the patient keep his gaze fixed on a distant 
object, for contraction will occur upon converging for 
a near object, such as the examiner's face. In a few 
cases the associated action in convergence may also 
be lost. Inequality of pupils may be present with or 



* Mendel lias reported some cases of children with undoubted typical symp- 
toms of tabes, the first appearing at the ages ten and eleven. In both in- 
stances there was undoubted syphilitic heredity and in one a vesicular eruption 
appearing after birth was treated with mercurial baths. It is now held that early 
appearing tabes is due to hereditary syphilis. 



SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. 1 37 

without the foregoing Argyll-Robertson character, or 
the latter may be unilateral only. 

An early symptom, when it occurs at all, (100 
out of 400 cases) is temporary diplopia due to paresis 
or paralysis of some of the exterior muscles of the 
eyeball. It comes suddenly without any exciting 
cause, lasts an indefinite time and disappears ; it may 
return later and then become permanent. The di- 
plopia is often very annoying to the patient, but it 
may be so slight as not to be noticed except under 
tests. Ptosis may be present with such ocular palsies 
or independently; it may be bilateral. 

Optic nerve atrophy occurs in about 10 per cent, 
of the cases (Leimbach's statistics give 6.75 per cent.). 
It is an early symptom and, indeed, may precede all 
others. It has been noted in many cases that the 
disease seems to spend its force upon the optic nerve, 
for the early appearance of the atrophy is not followed 
by farther development of the disorder, or this is 
retarded or postponed for years. The atrophy is the 
so-called primary atrophy, of bluish-gray or muddy tint 
when seen in ophthalmoscopic examination. It goes 
on to blindness. 

Disturbance in the functions of the bladder is very 
common in the disease, being found in more than 80 
per cent, of the cases, while as first symptom it 
occurred in 90 out of 400 cases, as second symptom 
in 119, and as third in 74. The disturbance may be 
a leakage if the desire to urinate is not at once 
yielded to, or it may be inability to pass urine 



138 SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. 

except by the aid of the diaphragm and abdominal 
muscles. 

A paralytic state of the rectum occurs, but much 
less often than the trouble with the bladder. 

Weakening of sexual power and desire, often to 
complete extinction, was found in 58 per cent,, and 
as a symptom belongs mostly to the early stage of the 
disease. 

The paresthesias already mentioned as early symp- 
toms of locomotor ataxia are most commonly felt in 
the feet or legs, especially in the soles and edges of 
the feet, less frequently but not rarely in the region 
of anus, perineum, scrotum and penis. More fre- 
quent than, the latter are paresthesias in hands and 
arms, while a special paresthesia in the ulnar distribu- 
tion has been observed often enough to give it a 
diagnostic value. The paresthesias vary in character. 
Some patients feel as if a layer of felt were 
under the soles or as if cushions were there, others 
feel a numbness or prickling or crawling ; sometimes 
a sensation of cold is complained of, and in one case 
the patient felt as if the sacral, anal, perineal and 
genital regions were closely packed in ice. Burning 
or "raw" sensation is not infrequently felt. 

Hypesthesia or even anesthesia (often with anal- 
gesia), retardation of pain sensation (pin-prick not felt 
for sometimes two or three seconds), allocheiria (pin- 
prick in one part felt in the analogous part of the 
other limb), often precede the occurrence of ataxia. 

The ataxia itself is but one form of anesthesia. 



LOCOMOTOR ATAXIA. I 39 

The so-called muscular sense fibres cannot carry the 
sensory impulse originating in the end organs in the 
muscles (or in the joints!). Hence the information 
to the brain of the position of a limb or any portion of 
it is insufficient and misleading, so that for the successful 
voluntary motion of any part the needed information 
must be obtained through the sense of vision. The 
patient, with eyes closed or in the dark, cannot co- 
ordinate his muscular actions, cannot stand with feet 
together without swaying (Romberg's symptom), cannot 
walk a straight line, and after the ataxic stage has 
well advanced cannot do these acts even with the 
aid of the sense of vision. For a time, however, he 
can walk by keeping the feet widely separated, so 
as to get a broad base of support, and by throwing 
the foot, as it were, forcibly, the heel reaching the 
ground first, thus making sure of each succeeding 
step. His greatest difficulties are going up and down 
stairs, and turning around while standing. 

When the ataxia reaches the upper limbs it is 
first observed in the finer movements of the hands, so 
that buttoning the clothing, writing, or playing a 
musical instrument becomes difficult, and the latter 
at last impossible. Ataxia of the arms is relatively 
infrequent, Leimbach's statistics showing its occurrence 
in only 17 cases out of 400, and all but two of the 
cases were those in which the disease was of long 
standing when the symptom appeared, or else of very 
rapid progress. 

The tests for ataxia are simple enough, and limited 



140 

in number only by the ingenuity of the examiner. 
To have the patient stand with feet close together, 
eyes being closed, and observe the swaying of the 
body in different directions; to have him lie down 
and with one heel endeavor to touch the knee 
of the other leg, or to put one heel on top of the 
toes of the other foot ; with the foot to describe a 
circle in the air ; to tell him to simply cross one 
leg over the other — all these are but a few of many 
possible tests, and in all even slight amounts of 
ataxia will be discovered by a mere novice. So with 
the arms. To direct the patient (eyes being closed) 
to bring the two forefingers together from a distance ; 
to have him touch with one forefinger successively, 
and each time from a distance, the tip of the nose, 
the middle of the forehead, the chin, the lobule of 
the opposite ear, _ are well-known methods. If ataxia 
exist, the movements, instead of being done grace- 
fully, as under normal conditions of co-ordination, are 
made unsteadily, doubtfully, and usually go wide of 
the mark. The simple test of crossing the legs when 
the patient lies with eyes closed will often tell the 
whole story. 

Although ataxia is due to impairment of co-ordina- 
tion, and is not a manifestation of muscular weakness, 
yet its increase means an excessive amount of mus- 
cular exertion when walking, so that, as it increases, 
the patient becomes more and more unable to make 
such exertion, and finally, perhaps after years, he 
becomes bed-ridden, and is in the so-called 



SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. 141 

paralytic stage. Meanwhile there are other symptoms 
present. 

The girdle sensation, as if a band or girdle were 
tightly constricting the waist or lower abdomen, oc- 
curred in 31 per cent, of 400 cases and even appeared 
as the initial symptom in 34 of these ; it is not diag- 
nostic of this disease, since it occurs in other forms 
of spinal cord trouble, nor is it continuous, but when 
present it is extremely trying to the patient. 

The so-called "crises" are of great importance 
diagnostic ally, but they do not appear to be frequent. 
Leimbach reports 17 cases of gastric crises (in 10 
of these the crises were the first evidence of the 
disease), 1 case of rectal crises and 3 of laryngeal 
crises, out of 400 cases of tabes. The crises are 
suddenly occurring attacks of disturbance in some 
organ without any recognizable adequate cause. 
Thus attacks of gastric pain with or without 
vomiting, sometimes nausea and vomiting with- 
out pain ; attacks of spasmodic coughing, simulating 
whooping cough ; and attacks of severe diarrhoea, 
often choleraic in character, are some of the crises. 
They may last a few hours or many, or even some 
days, and usually cease as suddenly as they came. 
Renal crises, consisting of severe pain in the region 
of the kidneys, accompanied by apparent suppression 
of renal activity; and clitoris crises or sexual orgasm 
in the female, have been noted by authors. Mobius 
classes with the crises attacks of paraesthesia in the 
rectum, the sensation being that of a thick stick or 



142 

similar body being thrust upward. In a case under 
the notice of the writer this sensation was an almost 
continuous one for months. 

Trophic disturbances occur during the course of the 
disease in a very small percentage of the cases, and 
arc confined to the bones and joint structures. The 
bones become fragile, the ends eroded or crumbling, 
the cartilage may disappear and spontaneous luxation 
occur, with deformity, due in great part to effusion 
and swelling, often of the whole segment of the limb, 
yet without evidences of inflammation. This latter 
manifestation is known as Charcot's arthropathie tabetique 
and is probably seen more often in hospital cases than 
in private practice. It affects the knee-joint most 
often, but other joints may be attacked. 

Trophic changes in the skin, such as eruptions of 
various kinds, may be looked upon as complications, 
but an intractable form of ulceration occurs at times 
on the sole of the foot as a result of slight injury, 
such as a trifling cut. 

Neuritis, of degenerative type, in the peripheral 
spinal nerves, occurs occasionally in advanced stages 
of the disease ; it may lead to atrophy of muscle, most 
often seen in the legs. 

The diagnosis of locomotor ataxia in any well de- 
veloped case is comparatively easy, the large number 
of the chief symptoms permitting variation, yet assur- 
ing such positiveness in the grouping of them into sets 
that error is practically impossible. Thus, any one of 
the following groups makes the diagnosis absolute : 



M3 

Lancinating pains in legs, Argyll-Robertson pupil 
and loss of knee jerk. 

Loss of knee jerk, optic nerve atrophy, and pares- 
thesias of feet. 

Paresis of eyeball muscles, weakness of bladder, 
lancinating pains. 

Similar groupings of the foregoing symptoms or of 
others may be made by the examiner, and if in ad- 
dition there is found Romberg's symptom or ataxia 
under tests, the diagnosis is beyond doubt. The 
crises may direct attention to the possible existence 
of the disease when they occur in the early stage. 

Multiple neuritis, after the acute symptoms have 
passed away, might be mistaken for tabes, since there 
are often present distinct ataxia, loss of knee jerks. 
Romberg's symptom, and in some cases optic nerve 
atrophy as sequel to a preceding optic neuritis. But 
the history of acute onset, rapid progress, tender- 
ness of nerve trunks, and presence of degenerative 
atrophy of muscles in the affected limbs, suffice for 
differentiation. It must be remembered, however, 
that peripheral neuritis does occur in a few cases of 
locomotor ataxia. 

Post-diphtheritic paralysis (neuritis) may involve the 
limbs and cause ataxia, loss of knee jerks, paraes- 
thesias, or paralysis of eyeball muscles, but the his- 
tory, and especially the paralytic symptoms of palate, 
pharynx and oesophagus as early secpiels of the throat 
affection will prevent confounding the later manifes- 
tations with tabes. 



144 SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. 

Not a few cases have been observed that began 
apparently as locomotor ataxia, and finally developed 
into dementia paralytica ; sometimes the reverse has 
been the case. In both, the eye symptoms may be 
common, and loss of the knee jerks is found in a 
not inconsiderable fraction of cases of general paresis 
of the insane. In doubtful cases time will be needed 
for determining the diagnosis. 

The anatomical changes found post-mortem in lo- 
comotor ataxia are first, because most conspicuous 
(even to the naked eye in most cases), a gray de- 
generation of the posterior columns, with the excep- 
tion of a small field anteriorly adjoining the gray at 
the posterior commissure, and extending laterally 
somewhat on each side. Next, Lissauer's zone at the 
end of the posterior gray horn, and the vesicular 
column of Clarke, show loss of fibres and cells, 
while the posterior nerve roots show marked atrophy 
of their constituent fibres. 

Just where the pathological process begins has been 
a fruitful cause of discussion. It has been maintained 
that a leptomeningitis exists with consequent constric- 
tion of the posterior nerve roots as they pass through 
the membrane and necessarily with neuritis and atrophy. 
It has been maintained that degeneration of the nerve 
roots is the starting point without any necessary 
meningitis. And finally it is held by many that 
the initial point is degeneration of the cells of the 
posterior spinal ganglia with extension of the process 
upward in the cord and downward in the peripheral 



H5 

fibres. The process attacks at times the spinal root 
of the fifth cranial nerve and the respiratory bundle in 
the medulla. The fibres of the tenth nerve or its 
posterior nucleus and the twelfth nerve nucleus are 
sometimes attacked. 

The Gasserian ganglion, which is analogous to the 
posterior spinal ganglia since its cells give rise to the 
spinal root (so called) of the fifth nerve, in some cases 
showed atrophy of its cells and fibres ; the optic nerve 
atrophy begins in the ganglion cell layer of the retina 
and extends backward. The motor nerves of the eye- 
ball, especially their nuclei and rootlets, may be af- 
fected ; the exact cause of the Argyll-Robertson symp- 
tom is, however, not yet definitely established, but it 
is presumed that some degenerative change exists in 
the central gray beneath the corpora quadrigemina. 

The changes in the cord first appear in the upper 
lumbar segments, except in those cases in which the 
disease affects first the arms, when the cervical seg- 
ments of the cord are first attacked. 

Prognosis. The outlook for cure of locomotor ataxia 
is practically hopeless, but in the first and second 
stages there is hope of lessening the pains and other 
trials of the patient. Even after the so-called para- 
lytic stage has set in there is a possibility of amelior- 
ating annoying symptoms. 

The disease lasts for many years, unless when blad- 
der trouble with its consequences occurs early. Death 
results from some intercurrent affection. 

The treatment of locomotor ataxia must be in the 



I46 SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. 

largest degree hygienic. Severe physical exertion must 
be avoided, but very moderate exercise in the open 
air is to be insisted upon. The food should be nour- 
ishing and easily digested. Stimulants and tobacco 
are to be forbidden, or allowed only in the smallest 
amounts. 

The ataxia and also (in some cases) the paresthesias 
and pains are lessened by the use of Frenkel's muscle 
drill or re-education of the muscles. This method 
consists in the carrying out of definitely ordered co- 
ordinated muscular actions in which the patient must 
use the will in directing the muscles. The* exercises 
are as varied as the directions in which his muscular 
co-ordination is lost, and are meant to utilize to the 
highest degree the few remaining sensory nerve fibres. 
It is not applicable when locomotion or the power of 
balancing is lost, nor when optic nerve atrophy has far 
advanced, as the eyes must be used to help correct 
faulty action. The exercises are in no sense gymnas- 
tics, strength as such not being sought. 

The use of galvanism alone (or combined with 
faradism) along the spine and limbs is recommended 
by some observers as serviceable in relieving many of 
the annoying symptoms; the current should be rather 
strong, 15 to 25 or 30 m-a. The writer has used it, 
but has seen no special results. 

Treatment by suspension in Sayre's apparatus, modi- 
fied so that the suspension is from the elbows (arms 
being flexed) as well as from the head, has in some 
cases been helpful, especially in relieving the bladder 



SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. 1 47 

symptoms. It should be gradual in beginning and 
ending, should be given every other day, two or three 
minutes at a time, during six or seven weeks. It is 
not admissible if arterio-sclerosis or bulbar symptoms 
are present, nor in the so-called paralytic stage. A 
mild form of suspension may be given by having the 
patient seated, so that the suspension shall use only 
the weight of the body above the hips at first. 

The employment of hydrotherapy is recommended 
by many ; the matter is one to be decided only after 
knowledge of the patient's susceptibility in this direction. 

Believing with Erb and Mobius that tabes is a 
post- or para-syphilitic disease, the writer has during 
the past few years used the principle of isopatlry 
in treating it, and has given Syphilinum, 200 
or higher. Marked improvement has been seen in 
some cases, but this may have been due to the 
patient's ceasing to use powerful drugs. Ergot has 
caused sclerosis of the posterior columns, as shown 
by post-mortem evidence, but Secale in different po- 
tencies, has not in the writer's hands influenced the 
disease in the least, undoubtedly because Secale was 
homoeopathic only in a gross way; in addition, the cases 
of poisoning by Ergot showed no progression in the 
affection produced. 

JEscidus Mppocastanum is said to have caused the 
disease; "whole flocks of sheep, having been fed dur- 
ing the winter on horse chestnuts, have been afflicted 
with Tabes Dorsalis, and many have died of it." * 

*Ad. Lippe, M. D., Homoeopathic Quarterly, April, 1870. The constriction 
in the rectum, which has been observed by the pro vers of ^Esctrfus, is often present 
in this disease. 



I48 SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. 

Four cases of cure are recorded by Bonninghausen 
under the use of Aluminum metallicum. Other observers 
have used with asserted benefit Argentum nitricum, 
Phosphorus, Plumbum metallicum and Picricum acidum. 
Physostigma, Lachesis, Nitric acid, Rhus toxicodendron, 
Silicea and Graphites have been credited with benefit- 
ing patients suffering from this disease. 

In the writer's hands Angustura vera materially 
helped in one case where the lightning pains were of 
great intensity. Carboneum sulphuratum ought to be 
of signal service in restraining at least the advance 
of the disease, while Zincum metallicum and Cadmium 
metallicum (vide Erb's statement quoted in article on 
Syringomyelia), should be borne in mind. Duboisia 
and Physostigma both cause unsteadiness on standing 
or walking with eyes shut, but in the former it would 
appear from other symptoms to be vertiginous in origin, 
in the latter probably neuritic. Lippe (Repertory) gives 
Nux moschata the first rank as a remedy for tabes 
dorsalis, and the next and only remedy, Phosphorus. 

From the foregoing it will be seen that in any 
case a close study of symptoms and especially of the 
ameliorations must be made ; if we are to increase 
our therapeutic resources in the treatment of loco- 
motor ataxia it must now be by recording all the 
symptoms and by collating the results of our prescrip- 
tions, and thus ascertain just in what respect and to 
what degree different remedies influence the course 
of the disease 

The various crises, including the lightning pains, arc 



ATAXIC PARAPLEGIA. 1 49 

treated according to the symptoms of each case, especial- 
ly the aggravations and ameliorations. At the present 
writing the pain crises, in a case in which the 
only relief is obtained while the painful part is 
immersed in water as hot as can be borne, have 
been evidently influenced by Strontiana carbonica 30, 
at frequent intervals during an attack. 

Ataxic Paraplegia. 

Whether the clinical picture seen in a case of 
ataxic paraplegia is due to a distinct pathological 
entity, or represents the results of separate disease- 
processes in the lateral and posterior columns re- 
spectively, cannot yet be decided. Certain it is, that 
cases having many of the distinctive symptoms of 
spastic paraplegia, and many of those of locomotor 
ataxia, do exist. It is plain, however, that a com- 
bination of the two diseases per se does not exist, 
and, indeed, cannot exist, for some symptoms of 
each are missing. 

The disease is described as beginning usually be- 
tween the thirtieth and fortieth years, but it has 
developed as early as the fifteenth and as late as the 
sixtieth year. It is considered by Gowers to be an 
isolated form of hereditary ataxia, but the writer has 
under observation the case of a boy aged twelve, unable 
to walk from the amount of paraparesis, the trouble 
having begun at least as far back as his eighth year, 
while he has double optic nerve atrophy (of the gray 
or primary variety) with exaggeration of the knee 



I50 SYSTEM DISEASES, ETC. — ATAXIC PARAPLEGIA. 

jerks, slight ankle clonus and hypertonicity of the 
paretic lower limbs — symptoms that exclude Fried- 
reich's disease absolutely. 

The early symptoms are those of spastic paraparesis 
with the addition of some ataxia. In the case men- 
tioned above, the first symptom of ataxia was noticed 
in the arms, the patient when trying to clap his hands 
failing to succeed. Weakness of the legs, with too 
ready fatigue, is seen, but the ataxia, present under 
the usual tests and conditions, has more the quality 
of reeling (when walking or standing) than that of 
locomotor ataxia. Lightning pains and the girdle sen- 
sation are present in rare cases and impairment of 
sensation is likewise rare. The knee jerks are exag- 
gerated, and usually ankle clonus can be elicited. 
The bladder may be affected (retention paralysis) 
while sexual power is frequently lost. Loss of the 
reflex mobility of the pupil has been observed in 
some cases, while optic nerve atrophy occurs at 
times. 

The disease advances chiefly in the direction of 
increasing weakness of the lower limbs, with spas- 
tic symptoms, when, of course, the ataxia is gradually 
overshadowed, the patient, it may be, after a lapse of 
years, becoming bed-ridden. 

Some cases appear to be predominantly locomotor 
ataxia, with an affection of the lateral columns super- 
added. 

The course of the disease is extremely slow, 
death occurring after many years, and then usually 



SYSTEM DISEASES, ETC. HEREDITARY ATAXIA. I 5 I 

from some intercurrent affection, pyaemia from septic- 
infection (bed-sores), or from nephritis, the result 
of long-lasting bladder trouble. 

In the causation of the disease syphilis seems to 
have no part, while suppression of perspiration, ex- 
cessive physical exertion, sexual excesses, etc., have 
been ascribed as immediate causes. 

A similar clinical picture has followed the use 
of Lathi/rus deer a (and sativus), and also the use 
of diseased corn (in Italy, under the name pellagra). 

The treatment of ataxic paraplegia should be that 
of chronic myelitis, but from the facts named in the 
preceding paragraph, Latliyrus cicera or sativus ought 
to be of decided service ; the writer lias used it 
in diffuse myelitis with secondary degeneration with 
great benefit. Ustilago may be tried in view of 
a possible relation to pellagra, although our prov- 
ings have shown its influence in the sexual sphere 
of women chiefly. 

Hereditary Ataxia-Friedreich's Disease. 

This affection is one of the so-called " family" 
diseases, and appears in several members of the 
same generation. It is believed to be due to con- 
genital fault, as often shown by the smallness of 
the cord, seen in autopsies of its victims. 

The symptoms of the disease appear first about the 
time of puberty in most cases, although there has 
been reported as occurring as early as the sixth or 
seventh year a distinct ataxia of the lower limbs, 



152 SYSTEM DISEASES, ETC. HEREDITARY ATAXIA. 

accompanied by some amount of muscular weakness. 
The gait is a modification of that of locomotor 
ataxia, since the weakness produces something of a 
"reeling" quality. Sensory disturbances are absent, 
lancinating pains having been only rarely noted, 
while hypsesthesia when observed has been only in 
the later stages. The knee jerk is lost early, as 
a rule. Choreiform movements occur in many cases, 
especially in the muscles of the neck, and then 
causing irregular oscillation of the head. The course 
of the disease is very slow, and several years may 
elapse before ataxia of the arms appears. Contrac- 
ture in different muscles causes at times scoliosis, 
or talipes, or hyperextension of the toes, etc. Dif- 
ficulty in speaking, the words being imperfectly 
enunciated, and nystagmus, are common features of 
the disease when it has well advanced. Paralysis 
of eyeball muscles, or loss of pupillary reflex, has 
been occasionally noted, but most observers insist 
that the eye fundus is always normal. Vesical 
troubles are extremely rare, and no " crises " occur 
in the disease. 

As the disorder progresses, increasing weakness of 
the lower extremities eventually confines the patient 
to bed. It may extend over a period of thirty or 
forty years, but death comes from some intercurrent 
disorder, and, of course, at any time. The prog- 
nosis for cure is hopeless, but with care and proper 
hygienic regimen, life will be prolonged. 

The anatomical changes, as shown by microsco- 



153 

pica! examination are confined to the spinal cord 
and medulla chiefly, and the smalm ess of the cord 
seen in all cases examined is taken as evidence of 
imperfect development. The disease is really a com- 
bined system degeneration of the column of Goll 
entirely, the column of Burdach in part, the crossed 
pyramidal tract, the direct cerebellar tract, and in 
some instances the ascending antero-lateral tract. 
Changes in the medulla have not as yet been suf- 
ficiently well studied to deduce positive conclusions 
therefrom. 

Spastic Paraplegia. — Spastic Spinal 
Paralysis. 

This disease-manifestation was formerly called pri- 
mary lateral sclerosis because of its clinical likeness 
to secondary degeneration (sclerosis) of the pyramidal 
tracts. 

Its existence as an independent primary disease is 
now so stoutly contested that it must be a rare affection 
if it exist at all. 

It is gradual in onset, weariness in the legs 
being first noted, advancing to paresis and later 
to paralysis, without sensory disturbance or trophic 
change, without implication of the bladder or rectum. 
A sense of stiffness is felt in the affected limbs, or a 
feeling as if the muscles were too short. 

The existing hypertonicity is shown by the markedly 
exaggerated knee jerks and, in well advanced cases, 



154 

ankle clonus or even a patellar clonus (on pulling on 
the quadriceps femoris by means of the patella) may 
be observed. The affected limbs undergo contraction 
at times, from fatigue or in attempting a movement. 
The contractions are temporary at first, but in course 
of time a condition of rigidity comes on mostly of the 
extensor and adductor muscles. In consequence, the 
gait becomes the well-known spastic gait, the knees 
nearly together, the legs slightly bent at the knee ; 
the steps taken are short and the balls of the feet 
scrape the ground, the heels not reaching it. 

At each step the weight of the body causes an ankle 
clonus, thus giving a quivering quality to the gait. 

The upper limbs may be affected in course of time 
with stiffness, impaired activity and increased deep 
reflexes. 

The affection is slow in its progress usually ; it may 
continue for years or may cease to advance. 

Sections made from the cords of those who had the 
affection during life have not shown an isolated primary 
disease of the pyramidal tracts, but have shown other 
diseases or secondary degenerations with implication 
of the lateral columns. The trouble is now believed 
to be in most cases a result of syphilitic myelitis, 
diffuse myelitis, multiple sclerosis, tumor of the cord 
or brain, syringomyelia or even hydrocephalus. 

Nevertheless, Oppenheim maintains the possibility 
of the existence of the independent primary affection, 
but in every case with these symptoms endeavor should 
be made to discover some cause such as those mentioned. 



SYSTEM DISEASES, ETC. SPASTIC PARAPLEGIA. I 55 

Hysteria is said to simulate the condition. 

The diagnosis is made chiefly by determining the 
presence or absence of any primary affection. In 
hysteria there may be a deceptive false clonus, but 
the onset of the symptoms is sudden and usually after 
some psychical excitement, while the rigidity has the 
peculiarity of hysterical contracture. 

The symptoms of spastic paraplegia in the adult 
appear between the 20th and 40th years, as a rule. 
The cause assigned is at times trauma or exposure to 
cold ; a preceding syphilitic infection or an acute in- 
fectious disorder or even lead poisoning, is stated by 
Oppenheim to be capable of developing the disease. 

The treatment should be that laid down in the 
section on chronic myelitis ; Lathyrus sativus or cicera 
has produced the symptoms. 



Non-Systemic Diseases of Spinal Cord. 



Multiple Sclerosis. — Disseminated or 
Insular Sclerosis. 

A condition in which numerous small foci of sclerotic 
change are distributed widely and irregularly through 
the brain and spinal cord. In size these foci vary 
from that of a pin's head to that of a large bean, and, 
while they occur in the gray matter, are in greater 
numbers in the white. In accordance with their pre- 
dominance in any special area or tract will the result- 
ing symptoms differ, so that theoretically a case may 
occur which cannot be diagnosticated during life. Cer- 
tain groups of symptoms, however, are so closely 
associated in the disease that most cases, as far as 
we can judge, can be diagnosticated. It is a disease 
seen mostly in early adult life, but cases have been 
reported in which it has appeared as late as the forty- 
fifth and as early as the fifteenth year. The writer 
has seen a case in which the tremor did not come 
on until the forty-seventh year, but the speech diffi- 
culty dated from early childhood. 

The etiology of the affection is unknown, but its 
manifestations frequently follow the cessation of some 
infectious disease, such as smallpox, scarlatina, measles, 
etc., or appear as the effect of trauma or of violent 
emotion. Striimpell has lately advanced the hypothesis 



MULTIPLE SCLEROSIS. I 57 

that the disease is primarily a multiple gliomatosis, 
due to inborn conditions. 

In a typical case the patient sliows a certain inter- 
ference with voluntary motion of the hands and arms, 
of the eye-balls and of the laryngeal muscles. The 
arms and hands, when the patient attempts any move- 
ment with them, are seized by a tremor, of small 
amplitude at first, but increasing in extent as the 
motion is continued. If told to take up a glass of 
water and drink from it, he shows a simple tremor 
on taking hold and the tremor becomes so wide in its 
increasing excursions that the contents of the glass may 
be violently thrown out. All the tremor ceases when 
the patient is at rest; but as the head and trunk 
muscles may be implicated they may continue in tremor 
when the patient is sitting or standing, because they 
are then in action. The eye-balls, when the gaze is 
directed to one side, show oscillation, known as nys- 
tagmus ; often the nystagmus is present when the 
patient simply looks* ahead. The speech difficulty has 
not been analyzed as to its muscular components, but 
is made up of somewhat jerky breaks in the emission 
of speech sounds, so that words are dissected into 
syllables and there is absence of the usual tailing and 
rising inflection commonly heard in ordinary conver- 
sation. From these peculiarities the speech of insular 
sclerosis is termed " scanning" speech or syllabic utter- 
ance. 

Besides the foregoing characteristic symptoms there 
are others of scarcely less diagnostic value. The 



158 NON-SYSTEMIC DISEASES OF SPINAL CORD. 

symptoms of spastic paraplegia are present in greater 
or less degree ; weakness, with stiffness of the legs, 
spastic gait, exaggeration of the knee jerks. 

Optic nerve atrophy is frequently seen in the 
course of the disease, more frequently than was for- 
merly supposed. (Buzzard.) It appears first as pale- 
ness of the temporal half of the disk, but eventually 
involves the other half, yet not with such loss of visual 
power as might be supposed from the ophthalmoscopic 
appearances. 

The mental state of the patient is altered; he is 
usually in a pleased or contented frame of mind, and 
fits of irrepressible laughter without cause, either ob- 
jective or subjective, are not infrequent in the early 
stage ; they have no relation to mental decay. (Oppen- 
heim.) 

Disturbances of sensibility, mostly paresthesias of 
fingers and toes, appear in some patients, but are only 
temporary. Attacks of vertigo are found in the ma- 
jority of the cases. During the course of the disease 
in some instances, apoplectiform attacks with perhaps 
complete loss of consciousness appear and are at times 
followed by a hemiplegia that soon disappears ; such 
attacks materially injure the patient. Occasionally 
paresis of the extrusor or of the detrusor of the 
bladder occurs, but does not become permanent. 

Aggregation of the islets of sclerosis or their in- 
creased size in some definite region will give rise to 
corresponding symptoms, such as atrophy, paralysis 
of bulbar nerves, or tabetic symptoms with loss of 



MULTIPLE SCLEROSIS. I 59 

the knee jerk (Growers); but the Argyll-Robertson 
pupil does not occur, although inequality of pupils 
has been reported; lightning pains have been observed. 
Paralyses of some of the muscles of the eve-ball are 
not uncommon, and optic neuritis has been noted. 

The disease may present a picture of transverse 
myelitis or of primary spastic paraplegia ; the cerebral 
symptoms already mentioned will place the affection 
nosologically, even when the typical symptoms are ab- 
sent; but dementia paralytica must be excluded. 

Pathologically, the islets show increase of con- 
nective tissue with loss of the medullary sheaths of 
the nerve fibres, while the majority of the axis cylin- 
ders remain for a long time. 

The development of the disease is slow, its course 
is very gradual ; it may last ten or fifteen years, but 
it may remain stationary for long periods and actual 
remissions occur. 

A neurosis has been described with many of the 
symptoms of multiple sclerosis, and hysteria has re- 
peatedly exhibited intentional tremor. Nystagmus is 
present in other affections of the brain and also in 
independent ocular troubles, and intentional tremor has 
been observed in connection with cerebellar lesion. 

The prognosis is absolutely bad as regards cure, 
but the possibility of cessation of advance or remission 
in the disease gives a certain hopefulness to the outlook 
in cases without threatening bulbar symptoms, or in 
those in which the apoplectic manifestations have not 
appeared. 



l60 NON-SYSTEMIC DISEASES OF SPINAL CORD. 

Treatment. Claims have been made that the dis- 
ease has been been benefited by the use of Physostigma 
venenosa, Argentum nitricum, Plumbum, Nux vomica 
and Phosphorus, but the writer has not been able to 
influence its course by any remedy. If Strtimpell's 
hypothesis of the essential nature of the disease be 
well founded, it might be possible to retard its pro- 
gress by our deep acting constitutional remedies such 
as Sulphur, Calcarea, Lycopodium, Silicea, Thuja occi- 
dentalis, etc. 

Acute Ascending Spinal Paralysis. 

Under this term Landry described a special form 
of disease in which, after some prodromal symptoms, 
general in character, a lax paralysis ensues, first in 
the legs and more in one than in the other in the 
beginning, with fever, and, in many cases, intestinal 
symptoms. The patient is compelled to remain in 
bed and the weakness attacks the muscles of the 
abdomen and then those of the arms. Next follow 
bulbar symptoms, consisting of difficulty in swallowing 
and in the use of the organs of speech. Attacks of 
dyspnoea, culminating in paralysis of respiration as 
the final term of the series, if continued, end the scene 
within a few days. 

The ordinary sensibility is not disturbed, the tendon 
reflexes are at first not changed, but later become 
extinguished, and the functions of the bladder and 
rectum are, as a rule, not affected. 

The electrical excitability of the muscles remains 



ACUTE ASCENDING SPINAL PARALYSIS. l6l 

undisturbed and there is no atrophy. There are also 
no mental symptoms. Profuse sweating is generally 
present, and some oedema may be observed. The 
fever may continue during the whole course of the 
disease. Enlargement of the spleen has been repeat- 
edly noted. 

The progress of the disease is rapid, in some cases 
the fatal end occurring within two or three days, 
or it may be delayed for a week or two. Cures do 
occur, but the convalescence is very slow. 

From the foregoing it will be seen that the prog- 
nosis is serious, and as all the cases reported do not 
seem to be of one character, it is difficult to assign 
any given case to a definite place in classification. 
Some are undoubtedly instances of multiple neuritis, 
and some appear to be cases of myelitis, but perhaps 
the real character of the affection is that of acute 
ascending infectious neuritis, with final implication of 
the structures of the medulla and possibly of the cere- 
brum. From the symptoms, PJiosjrfiorus, Oxalic acid, 
Lathyrus sativus, Ledum pdlustre and Aluminium metal - 
Ileum would appear to be indicated. 

The Caisson Disease.— Diver's Paralysis. 

In laying the foundations of bridges or in other 
work done at considerable depths below the surface 
of the water, the workmen are in an atmosphere 
whose pressure is two, three or, in some instances, 
five times that of the ordinary atmosphere. 

Under the pressure mentioned the men suffer but 



162 NON-SYSTEMIC DISEASES OF SPINAL CORD. 

little, if at all ; indeed, there is a sense of stimulation, 
but if the pressure be rapidly lowered there come 
on in a short time some serious or even dangerous 
symptoms which are relieved if the patient can be 
returned to the pressure chamber. If the pressure 
be gradually reduced to that of the ordinary atmos- 
phere no ill effects follow, and an arrangement of 
chambers with successively decreasing pressure has 
been in use, through which the worknen pass into 
the outside air, staying for a time in each ; or, lately, 
one intermediate chamber only, with a means of slow 
escape from it of the compressed air, serves even 
better the desired end. 

When through the recklessness of the workman or 
insufficiency in the method of lowering the pressure, 
the change from the working pressure to that of the 
outside air is made too rapidly, the symptoms of the 
disorder come on. 

Under the influence of increased atmospheric 
pressure there is taken up through the lungs a 
proportionally increased amount of the constituents 
of the inspired air, in accordance with the physical 
law of absorption of gases by liquids. If the pres- 
sure is gradually lessened the absorbed gases are 
gradually released from the circulation, through the 
lungs and without damage ; if the pressure is 
rapidly lessened, the absorbed gases appear as bub- 
Ides within the containing liquid. In the case of 
the larger blood vessels, these are passed along in 
the circulation, but in the case of small vessels, 



THE CAISSON DISEASE. 1 63 

and especially the terminal arteries, the minute 
bubbles act as emboli, occlude such vessels, and cut 
off the blood supply to the area of tissue supplied 
by them. According to Kadyi, the arteries supply- 
ing the lateral and posterior aspects of the cord 
are smaller than those of the anterior and central 
portions, and in the whole dorsal extent of the 
cord the vessels are especially small. Consequently 
this part becomes the site by predilection for the 
gas emboli, with consequent spinal symptoms and 
secondary degenerative changes in the cord. The 
liberation of the gas in minute bubbles outside of 
the blood vessels, or through them and the pos- 
sible production thereby of minute fissures in the 
cord, are of much less importance than the areas 
of necrosis, softening and reactionarv inflammation 
set up in the cord in the manner stated. A full 
discussion of the subject is given in a paper by 
Dr. A. Hoche, of Strasburg, in Berliner kliuische 
Wochenschrift, 22, 1897. 

The symptoms are felt in from two to thirty 
minutes after leaving the pressure chamber too 
rapidly, some time being required for the evolution 
of gas bubbles. 

Nitrogen is the chief constituent of the gas bub- 
bles, it not being so readily held by the blood as 
oxygen or CO 2. 

The symptoms are evidently of spinal . and cere- 
bral origin : vertigo, pain and noises in the ears, 
nausea, and even vomiting, with weakness in the 



164 NON-SYSTEMIC DISEASES OF SPINAL COED. 

legs. Intense neuralgic pains in the muscles and 
joints of back and lower limbs, with anaesthesia of 
the surface of the legs, and often with retention of 
urine. Slight cases recover in a few days or a 
few weeks ; severe ones may die early, or after 
lingering for some months. Permanent damage to 
the cord, with secondary degeneration, is often the 
sequel, as shown by paraplegia, paresis of bladder, 
etc. 

The greater the pressure and the longer the 
time the worker remains in the working chamber, 
the greater is the amount of gas taken up by the 
blood; hence the need of gradually lessening the 
pressure as the workman passes out into the ordi- 
nary atmosphere. 

As soon as symptoms appear, the patient should 
be returned to the pressure chamber until relieved, 
and then slowly emerge into the open air through 
the graded pressure chambers. Even up to the 
third day this should be done, for P. Bert in his experi- 
ments on the effects of increased atmospheric pressure 
on animals, found on the fourth day after symp- 
toms had developed, gas emboli and blood coagula 
within the vessels of the spinal cord. 

Otherwise the treatment by internal remedies 
should be symptomatic. Arnica and Rhus toxico- 
dendron would appear to be the best suited to the 
early symptoms ; later, the case may be treated as 
one of chronic myelitis. 



TUMORS OF THE SPINAL CORD. 1 65 

Tumors of the Spinal Cord. 

In the section on Compression Myelitis, tumor 
within the spinal canal is mentioned as a cause of the 
symptoms, yet the subject of tumor within the canal 
needs separate consideration. 

Tumor affecting the spinal cord is most often 
meningeal in origin, less frequently it arises within 
the cord itself, and rarely from the vertebrae. It 
may, therefore, be between the dura and the bony 
wall of the spinal canal, or enclosed within the mem- 
branes, or between the membrane and the cord itself, 
or wholly within the latter. 

In the first three cases the eifect of a tumor is 
to produce compression of the cord, often with great 
irritation of the nerve roots, with symptoms resulting 
therefrom ; in the fourth case the symptoms will be 
those of diffuse myelitis, at times with peculiar dis- 
sociation in the qualities of peripheral sensibility, as 
in syringomyelia (q. v.). 

Tumors arising from the meninges are sarcomata, 
myxomata, enchondromata and lipomata; those occur- 
ring in the cord itself are gliomata, sarcomata, gum- 
mata and tubercle. 

Tumor of the cord is generally small, but glioma 
and sarcoma may involve many segments of the cord. 
Solitary tubercle may be as large as a hazel-nut. 

The symptoms of tumor of the spinal cord already 
mentioned become peculiar in their distribution when 
only one lateral half of the cord is affected. The 
result then is Brown-Sequard's paralysis, in which 



1 66 NON-SYSTEMIC DISEASES OF SPINAL CORD. 

there is motor paralysis and absence of the muscular 
sense below the site of the tumor and on the same 
side, while sensory paralyses, chiefly of the pain and 
temperature senses, are found in the corresponding* 
parts of the opposite side. At the level of the lesion 
a band of anaesthesia on the side of the lesion, and 
one of hypersesthesia in the corresponding part of 
the opposite side exists. 

With meningeal tumors the irritation of the nerve 
roots causes severe pain in the distribution of the 
nerves so irritated, and such pain may long precede 
the symptoms of compression of the cord. 

From irritation of the nerve roots, spasmodic con- 
tractures of the limbs are observed; they may be 
very severe. 

The reflexes are increased when the lateral columns 
are affected, except when the lesion is situated in the 
lumbar enlargement of the cord, and then the knee 
jerks are absent. 

Paresthesias, hypeesthesia, or anaesthesia may exist. 

Paralysis comes on in the course of time ; it may 
be of one or of all four extremities, according to the 
site and lateral extension of the tumor ; some atrophy 
may be present. 

Death follows from exhaustion, or sepsis, preceded 
by paresis of bladder and rectum and formation of 
bed-sores in a considerable proportion of cases. 

The pathological changes resulting from tumor of 
the cord are flattening, and decrease in its size in 
cross-section, with marked softening, studded with 



TUMQRS OF THE SPINAL CORD. 1 67 

small haemorrhages. Secondary degeneration and re- 
active inflammation serve to complicate the symptoms 
of the case. 

The diagnosis is to be made from Pott's disease, 
transverse myelitis and pachymeningitis cervicalis 
hypertrophica. In the first, the age of the patient, 
the presence of tuberculous trouble elsewhere, and 
the marked stiffness and painfullness of the vertebral 
column, together with angular projection of some of 
the spines, are decisive. In the case of myelitis 
there is not the gradual increase of the symptoms, 
nor the succession of them found in tumor of the 
cord. At the same time it must be held in mind 
that a tumor wholly within the cord will usually not 
give rise to the severe neuralgic pains found when 
the neoplasm is outside of it. Pachymeningitis is to 
all intents and purposes an extra-myelonic tumor. 

The character of the tumor may be inferred if in any 
other part of the body a tumor exist; gumma may be 
inferred from antecedent history of syphilitic infection. 

Tumors arising from the membranes show but 
little tendency to invade the structures of the cord, 
and the latter exhibit a remarkable resisting power 
to the increasing pressure (A. Westphal). 

The prognosis of tumor within the spinal canal is 
absolutely bad, but surgical interference has occasion- 
ally rescued the patient from his threatening fate. In 
a study of 123 cases, of which 100 were described 
in detail, by M. Allen Starr, 22 cases were operated 
on, yet in only 6 were the patients relieved of the 



1 68 NON-SYSTEMIC DISEASES OP SPINAL CORD. 

paralytic symptoms, probably because surgical inter- 
ference was at too late a period. Starr states that 
most intraspinal tumors are malignant, and that al- 
though this darkens the prognosis, still operation 
should not be refused, provided the tumor is extra- 
myelonic, which fact is difficult of ascertainment. He 
considers as evidences of intra-myelonic tumor, Brown- 
Sequard paralysis, early degenerative atrophy, trophic 
changes and bedsores, and the appearance of analgesia 
before anaesthesia. 

The medicinal treatment of intraspinal tumor can- 
not be on the diagnostic indications, for the tumor 
is simply a foreign body within the spinal canal, 
irritating and compressing nerve roots and cord 
structures. The symptoms thus produced are not 
those of the disease itself. Hence, if prescribing 
our remedies is to be of service they must be chosen 
according to the symptoms of the patient's person- 
ality, the aggravations, ameliorations, etc. If the diag- 
nosis of tubercle or of syphiloma can be fairly as- 
sumed, the isopathic method may be of value, and 
in the latter instance the use of the remedies sug- 
gested in the section on syphilis of the spinal cord 
is recommended. 

Syringomyelia. 

Proliferation of glia cells and fibres in the central 
gray of the cord results in the formation of a tumor, 
a glioma. Increasing growth compresses the blood 
supply at its periphery and the centre breaks down, 



SYRINGOMYELIA . 1 69 

forming a cavity more or less tubular, and to this 
condition the term syringomyelia is applied. 

As the central gray is invaded and in part destroyed 
the symptoms are peculiar. 

The cause of the trouble is primarily an inborn 
defect or morbidity of the affected region itself, but 
often some exciting cause (trauma) is needed to start 
the process into activity. 

The symptoms of the disease manifest themselves 
most often in late youth or early middle life. In one 
or both hands a slowly progressive muscular atrophy 
appears, perhaps preceded by some pain, vague in 
character. The atrophy is similar to that observed 
in progressive muscular atrophy of spinal type and, 
like it, it may first appear in the muscles above the 
elbow or around the shoulder. Fibrillary contractions 
may be noticed in the atrophying muscles, whose 
electrical contractility is lessened or changed at times 
to the reaction of degeneration. The grouping of the 
muscles affected depends upon the direction in which 
the gliosis advances in the cord. Most frequently it 
involves the cervical enlargement, often implicates the 
dorsal segments, rarely the lumbar portion. 

The special and characteristic clinical feature of 
the disease is the peculiar anaesthesia for certain 
qualities of sensation. In the affected member and 
over a larger area than that of the atrophy, there 
is loss, often complete, of sensation for pain and for 
temperature, so that a needle prick or the faradic 
current is not appreciated as such, and hot or cold 



I 70 NON-SYSTEMIC DISEASES OF SPINAL CORD. 

bodies when applied to the anaesthetic region cannot 
be differentiated from simple touch, tactile sensation 
being retained. The muscular sense is not impaired. 

Paresthesias, a feeling of cold or of heat or a mix- 
ture of the two, are present # in most cases, but sub- 
jective pain is rare. 

Trophic and vaso-inotor disturbances are frequent. 
Blebs and bullae may form upon the skin of the 
affected parts and, bursting, leave ulcers often difficult 
to heal. Eruptions, eczematous or herpetic, are not 
infrequent, while bluish-redness or oedema of hands 
or arms has been observed. Panaritia with anaesthesia 
and analgesia (Morvan's disease) has been so often 
associated with syringomyelia that it is held by many 
to be a manifestation of the disease ; others, however, 
maintain that it is due to associated neuritis. Scoli- 
osis and kypho-scoliosis may appear in the course of 
the affection. From pressure on the lateral pyramidal 
tracts there may follow at a somewhat advanced period 
spastic paraparesis. 

The gliosis may predominate in one-half of the 
cord, when the symptoms will be practically unilateral ; 
it may extend in more than one direction or have 
more than one cavity; it may extend upward, involv- 
ing the medulla, and so give rise to bulbar symptoms; 
if it extend low down in the cord, the legs will be 
affected in the same way as the arms. 

Inequality of pupils is not rare, and concentric 
narrowing of the visual fields often exists. (Gold- 
scheider.) 



SYRINGOMYELIA. I/I 

Diagnosis. In a typical case the peculiar sensory 
disturbance with the associated atrophy will be suf- 
ficient for the diagnosis. But not all cases are typical 
and when the sensory symptoms are absent it will be 
impossible to decide between this disease and pro- 
gressive muscular atrophy of spinal type or amyo- 
trophic lateral sclerosis. 

Hydromyelia. By this term is meant a congenital 
condition analogous to and at times associated with 
hydrocephalus, in which the central canal is widened 
tor a greater or less extent, usually more posteriorly 
than anteriorly, and at times irregularly. Unless path- 
ological changes occur in its walls and adjoining tissues, 
it has no clinical importance. 

The treatment of syringomyelia can only be symp- 
tomatic and then not guided so much by the diagnostic 
symptoms as by those that characterize the patient, 
such as his aggravations and ameliorations or peculiar 
symptoms not part of the special trouble. 

It is interesting to note a report of two case- 
having all the symptoms of syringomyelia which 
appeared alter ''running" a chip or shaving of 
zinc into a finger and a thumb, respectively, reported 
by Dr. Joseph Mies of Cologne (Munch, med. Woeh- 
enschrift, 19, 1896). The men were both healthy at 
the time of the injury, one aged 40, the other 33. 
The symptoms were gradual in development ; in one 
case the diagnosis of progressive (spinal) muscular 
atrophy was made after some four years, the temper- 
ature and the pain sense not being then affected. 



172 NON-SYSTEMIC DISEASES OF SPINAL COED. 

After eight or nine years the temperature and pain 
senses were found affected. The other case was more 
rapid in its progress, but the results were the same. 
The reporter considered the symptoms to be the re- 
sult of slow poisoning by zinc, and compares the cases 
to those reported by Schlockow as cases of peculiar 
spinal cord affections in workers in zinc. 

Eulenburg, in commenting on Mies' cases, rejects 
the theory of chronic poisoning by zinc, and con- 
siders an ascending neuritis to be the middle link 
between the peripheral injury and the consecutive 
spinal cord affection. (Deutsche med. Wochenschrift, 
29, 1896.) He further considered that Schlockow's 
cases of various troubles, due to inhaling the vapors 
of zinc, were chargeable to impurities present, es- 
pecially arsenic, cadmium and lead. 

It may be worth noting that in both of Mies' 
cases the splinter or shaving of zinc had been 
touched with ordinary hydrochloric acid, which may 
have made in the wound zinc chloride, a soluble 
poisonous compound. 

Treatment. Since the affection is an invasion of 
the cord by the proliferation of glia cells, the symp- 
toms will vary according to the parts of the cord 
affected either destructively or by pressure. To pre- 
scribe on such indications cannot be expected to in- 
fluence the advance of the real disease. Hence, the 
diagnostic symptoms should not be taken into ac- 
count in searching for a remedy, but reliance placed 
on the symptoms of the patient that are constitu- 



SPINAL IRRITATION. 1 73 

tional, the times and conditions of aggravation, ameli- 
oration, etc. The possibility of special influence of 
the metals mentioned in causing organic change within 
the cord should be held in mind in prescribing for the 
disease. 

The manifestation termed Morvan's disease, whatever 
be its cause, would lead us to use remedies known to 
be of especial service in panaritia, such as Dioscorea 
vittosa, Natrum sulphur icum, Silicea, Sulphur , Hepar 
sulphuris calc, etc., but analgesic panaritium is a 
special manifestation not as yet noted in the provings. 

Spinal Irritation. 

Under this name a set of symptoms referable to 
the posterior or sensory spinal nerve roots, is fre- 
quently found in hysteria, neurasthenia, or may exist 
alone. 

The symptoms are pain in the back with tender- 
ness to pressure or at times even to touch and often 
with a subjective sensation of burning. The patients 
complain of tiredness on exertion and the exertion is 
apt to increase the painful sensations in the spine. 

Painful pressure points may be found at the sides 
of the vertebrae, about the lower cervical and upper 
dorsal and in the lower dorsal and upper lumbar 
regions. Pressure may result in simple increase of 
the already existing pain, in the production of an added 
sensation of soreness in situ, or in causing pain or 
other annoying sensation in the limbs or other distant 
parts. 



1 74 NON-SYSTEMIC DISEASES OF SPINAL CORD. 

When the seat of the trouble is in the lower cer- 
vical or upper dorsal region, the use of the arms, as 
in holding a book, in sewing, or in doing up the hair 
(in women) aggravates the condition. In one case the 
midcervical region seemed most affected, and then the 
pressure of the coat collar was intolerable. If the 
dorsal region is affected, the patient may be unable 
to sit with the back resting against the back of a 
chair. 

Symptoms of neurasthenia or hysteria are often pres- 
ent, and are given under those heads. 

The affection appears in adolescence and in early 
adult life, and, as it is often slow in onset, adequate 
cause may not be discoverable ; the general terms 
overwork, worry, overstudy, etc., may mean much or 
little in this connection. The writer has seen the 
affection in a number of cases follow an attack of 
grippe. As cases have been cured by relieving uncor- 
rected errors of refraction or other ocular troubles, 
intrapelvic disorders, etc., it has been assumed that 
such conditions are etiological factors in producing the 
affection. Sexual over-indulgence, whether in a normal 
or abnormal manner, is a causal factor in many cases. 

The lowered vascular tonus, as evidenced by relaxed 
blood-vessels of face and hands in many cases, is prob- 
ably existing within and will account for the spinal 
.symptoms ; engorgement, especially of the veins with- 
in the spinal canal, results in pressure and irritation 
of the nerve roots, particularly of the posterior or 
sensory ones ; and most of the associated symptoms, 



SPINAL IRRITATION. I 75 

such as weak digestive power, constipation or diar- 
rhoea, palpitations, etc., may be thus accounted for, 
either directly or indirectly. 

The knee jerks are generally exaggerated. 

The diagnosis is to be made between this affection 
and an organic disease, such as compression myelitis, 
spinal meningitis or meningo-myelitis. In organic af- 
fections there is motor weakness, often with rigidity, 
the weakness may amount to paresis or paralysis, or 
the pains radiate from the spine instead of being 
limited to it. The history, the continuance of the 
symptoms for long periods without much change, the 
absence of paralysis of bladder or rectum, are in favor 
of spinal irritation. 

The prognosis for cure is good. 

Treatment should be both medicinal and hygienic ; 
it will be given in the section on neurasthenia. 



The Cranial Nerves. 

During the last few years the effort has been 
made (and with a large measure of success) to ap- 
ply the rule of uniformity to the origin of both the 
cranial and the spinal nerves. The latter, as has 
been stated in the section on the spinal cord, arise 
in two ways : the motor nerve fibres from large 
ganglion cells in the anterior gray horns, the sen- 
sory fibres from the posterior spinal ganglia, whose 
cells give off fibres that at a short distance divide, 
one part going to the periphery and ending there 
in free division or in a specially developed end 
organ, the other part passing into the region of the 
posterior gray horn of the cord. 

Of the cranial nerves, those having motor function 
arise from large cells aggregated in masses within 
the brain structure, such masses being analogues of 
the cell-groups in the anterior gray horns of the cord. 

Similarly, some of the cranial nerves subserving sen- 
sation, notably the auditory, and part of the fifth, arise 
from ganglion cells outside the brain structures proper. 

In the case of the olfactory and visual functions 
the analogy is not so close. 

On the base of the brain is seen anteriorly on each 
side, lying in a groove or sulcus at the bottom of the 
frontal lobe, the so-called olfactory nerve, whose 
anterior end is somewhat enlarged into the olfactory 



THE CRANIAL NERVES. 1 77 

bulb, which is the residue of an enormous develop- 
ment of brain structure in animals endowed with the 
olfactory sense in a high degree. 

The olfactory bulb contains specialized globular 
structures known as glomeruli, granular cells and star 
cells and giant ganglion or "mitral" cells. 

Buried in the mucous membrane of the upper and 
inner nasal cavities, besides the epithelial cells proper, 
are specialized olfactory cells from which there 
pass backwards fibres through the cribriform plate 
which then almost immediately end in a brush work 
that half surrounds a glomerulus in each case on 
entering the olfactory bulb. 

The opposite half of the glomerulus is enclosed by 
the brushy endings of the dendrites of a mitral cell. 

It would therefore appear that the peripheral neu- 
rones of the fila olfactoria form the real olfactory nerve 
and that the fibres going brainwards from the mitral 
cells (secondary neurones) form an intermediate tract 
which at the anterior perforated space divides into 
three so-called roots. The outermost is the largest 
and its fibres end in the cortex of the hippocampus; 
the middle division is poorly developed in man; the 
fibres of the internal division pass through the anterior 
commissure to the cortical area of the other side. 

Loss of the power of smell is most frequently due 
to disease of the mucous membrane affecting the in- 
cluded olfactory cells and nerve fibres, to nasal poly- 
pus, to dryness of the nasal mucous membrane due 
to trophic changes following paralysis of the fifth nerve, 



178 THE CRANIAL NEEVES. 

or to obstruction in the lachrymal canaliculi. Falls 
and blows upon the head may cause laceration and 
separation of the filaments of the nerve proper from 
their connection with the cells of the olfactory bulb. 
Disease in the anterior fossa, such as tumor, menin- 
gitis, bone affection, may cause compression of the 
olfactory bulb and tract. Excessive olfactory stimula- 
tion has caused loss of the faculty (Growers) and senile 
atrophy of the bulbs has occurred in old age. 

With the loss of the sense of smell, the sense of 
taste is usually lost for "flavors," the latter being 
appreciated via the posterior nares. Loss of the 
former with retention of the latter is due to disease 
of the mucous membrane in the upper part of the 
nasal passages. 

Anosmia, due to cortical disease or to disease back 
of the internal capsule, cannot be diagnosticated by 
the olfactory symptoms alone. The combination of 
aphasia and right-sided hemiplegia with left-sided 
anosmia has been observed several times ; it is prob- 
ably due to implication of the external olfactory root, 
near the island of Eeil. 

Functional anosmia is seen at times in hysteria and 
neurasthenia ; in the former it may be part of the 
hysterical anaesthesia. 

Congenital absence of the olfactory tracts and bulbs 
has been met with. 

Hyperosmia or increased sensitiveness of the olfac- 
tory nerves is seen at times in the hysterical and the 
insane. 



THE CRANIAL NERVES. 1 79 

Hallucinations of smell occur at times in the in- 
sane, and occasionally as the aura preceding an epi- 
leptic spasm. 

Parosmia, or perversion of the sense of smell, is 
a rare condition, in which every impression made 
upon the olfactory nerve is translated, so to say, 
as a disagreeable odor, always the same. The con- 
dition is probably cortical. 

Treatment must be influenced by the diagnosis 
of the underlying condition, and hence examination 
of the nasal passages, as well as a knowledge of 
the history, is imperative. If local conditions, past or 
present, place the affection in the category of purely 
nervous trouble, the matter of treatment becomes 
that of the cause. In the absence of such condition 
other symptoms must be relied on for making a 
diagnosis of causes within the cranium ; if neither 
these nor intra-nasal disease be present, the treat- 
ment must be purely symptomatic. 

The prognosis in the nervous forms, whether of 
the bull), tract or cortex, is not encoura^ino:. 

The optic nerve is similar in its beginning to 
the olfactory. The rods and cones of the retina 
are the specialized sensory end organs of vision. 
The former terminate in prolongations, with knobbed 
ends, the latter divide each, and then give off short 
branchings. So-called horizontal cells connect func- 
tionally the endings of the neighboring groups of 
rods, while another set of cells carry impulses from 



180 THE CRANIAL NERVES. 

rods and cones to large ganglion cells, from which 
arise the long nerve fibres that pass brainward. If 
we push our analogy, we may say that the rods and 
cones, with their endings, form the real optic nerve. 

All the fibres of what has hitherto been under- 
stood as the optic nerve are not centripetal in their 
course. There are centrifugal ones, probably from 
cells of the anterior corpora quadrigemina. 

The optic nerve, as we must continue to desig- 
nate the long nerve fibres, passes backward and 
toward the middle line, where a partial decussation 
with the nerve of the other side takes place, and 
in such manner that the fibres from the inner halves 
of the two retinas cross, those from the outer half 
of each retina continuing on their own side. 

Behind the crossing, or chiasm, the mass of fibres 
is termed the optic tract. It winds around the cms 
of its own side and passes upward, giving most of 
its fibres to the external geniculate body, a few only 
to the anterior corpus quadrigeminum of the same 
side. From cells of the external geniculate body 
new fibres arise, which pass backward as the optic 
radiations of Gratiolet, and end in the cortex of the 
cuneus and its continuation on the posterior aspect 
of the first occipital convolution. 

In the cortex of the occipital lobe both retinas 
are represented, the light-impulses from the outer 
half of the retina of its own side, and those from 
the inner half of the opposite retina being brought 
together. Fig. 22, from Bechterew, gives a diagram- 



HE CBAXIAL XEBVES. 



181 



matic representation of the course of the fibres, and 
explains also the production of hemianopsia by a le- 
sion affecting the fibres anywhere behind the chiasm. 

Fig. 22. From Bechterew. 
The course of the light-im- 
pulses from their starting point 
in the retina to their arrival in 
the cortex (cuneus) is shown. 
The fibres, from the inner half 
of each retina, are seen to 
cross at the chiasm ell ; the 
optic tract ends in the exter- 
nal geniculate body iiyc, and 
the anterior corpus quadrige- 
minum of the same side, qa ; 
some fibres may end in the 
posterior mass of the optic 
thalamus, p, tit. New fibres 
arising from these structures 
form the optic radiations t)'V, 
and end in the cuneus C- The 
commisure of Meynert,CJ/,and 
that of Gudden, eg, have no- 
thing to do with carrying light 
impulses, but connect the large 
basal ganglia of the two hemi- 
spheres, probably. 

The retina is designated by 
the part marked /'. The pupil 
is not represented, but it is 
readily understood that rays of 
light from the right must im- 
pinge on the left half of the 
retina. A lesion at no is seen 
to affect all the fibres from the 
retina of the left eye ; hence 
no light impulses can pass 
back, and that eye is totally 
blind. A lesion in the optic 
tract, at tro or at I, is seen to 
affect only the fibres coming 
from the left half of each re- 
tina. Hence each eye is half- 
blind and in the same-named 
half of each retina. This hemi- 
anopsia takes its qualifying 
word not from the half of each 
retina, but from the absent half 
of the visual field. In the 
case assumed the lesion is in 
the left optic tiact or in the 
left optic radiations, and there 
must exist loss of vision in the 
Tight half of the field — that is, a right hemianopsia. 

A lesion at ch will affect the decussating fibres only, and there will result a bitemporal hemi- 
anopsia ; while to produce a bi-nasal hemianopsia there must be two lesions one on each side of 
the chiasm. 

The optic nerve is the only nerve that is access- 
ible to inspection ; here, by the aid of the ophthalmo- 
scope, the retinal expansion of the nerve can be 
studied in health and disease, and alteration of func- 
tion or structure is, speaking generally, as much the 
subject of neurology as of ophthalmology. Strictly 
speaking, diseases of the retina itself, such as retin- 
itis albuminurica, retinitis pigmentosa, or choroido- 




182 



THE CRANIAL NERVES. 



retinitis syphilitica belong to the latter department 
of medicine, yet they must be recognizable by the 
student of the former. 

On the other hand, the atrophies seen in the disk, 
whether primary (in association with degenerative 
disease of the spinal cord or brain), secondary (re- 
sulting from injury to the nerve at or in front of the 
chiasm) or consecutive (to optic neuritis), are of the 
highest interest to the student of nervous diseases. 

Testing the visual acuteness, the color sense and 
the visual field is often a necessary part of the ex- 
amination in nervous disease, since the results thus 
obtained may be decisively diagnostic or of high cor- 
roborative value. 




Fig. -i-6. 

Fig. 23 From Baas. Outlines of the visual field of the right eye, 
lessening of whose outline is abnormal (Forster's minimal visual field). 
The fields for colors are indicated by the different methods of outlining, 
the key to which is at the lower right of the figure. 

The lines gathering together in the centre indicate the coming to- 
gether of fibres from different parts of the retina and meeting to form 
the optic nerve at the disk, beneath which they assume their medullary 
sheaths. 

The pupillary reflex must be tested both directly 
and consensually. In the former, if no light-impulses 



THE CRANIAL NERVES. 1 83 

are sent back to the primary optic centre, no reflex 
contraction of the pupil can occur, but if light enter- 
ing the other eye affects the pupil of the first one, 
we know that the third nerve of the first is not at 
fault and that the trouble is loss of conduction in the 
optic nerve of that eye. 

So in hemianopsia we may obtain valuable information 
by the hemiopic pupillary test as to the site of the le- 
sion. If by means of a plane mirror light be thrown 
on the half of the retina now rendered useless by the 
lesion, when the lesion is not further back than the 
corpora quadrigemina, the pupil will not respond; if 
the lesion is in the occipital cortex, or in the optic 
radiations between the cortex and the corpora quad- 
rigemina (and external geniculate body, optic thal- 
amus), the pupil will respond. The test is, however, 
difficult ot application, but, theoretically, its value is 
great. 

Loss or lessening of visual power often bears no 
relation to the evident change in the disk or head of 
the nerve. In papillitis, or so-called choked disk, the 
swelling may be very great, yet loss of vision be 
slight, and vice versa {vide section on brain tumor). 
On the other hand, loss of visual power may be due 
to error of refraction, and disappear as soon as the 
error is corrected by proper lenses. Hence the stu- 
dent of this branch of medicine should possess and 
be able to use a case of trial lenses. 

Mapping the field of vision often tells a great deal. 
Central scotoma means loss of conduction of the 



1 84 



THE CRANIAL NERVES. 



fibres occupying the middle of the nerve trunk be- 
hind the orbit ; loss in the periphery of the field 




Fig. 24. 

Fig. 24. From Baas. The visual fields of a case of left homonymous hemianopsia. The 
dividing line between the seeing and non-seeing halves, is seen to be perpendicular, but without 
curving around the centre or fixation point, as it usually does. In this instance, however, the field 
for green is seen to extend beyond the centre. 

may mean an affection of the fibres at the outside 
of the nerve trunk, or simply a lessening of con- 
duction in all the fibres, normal vision being less 
acute at the periphery of the field. 
Changes in the color sense are to be expected 



THE CRANIAL NERVES. 



I8 5 



in optic nerve atrophy, and often precede ophthal- 
moscopic evidences, or even material contraction of 
the field for white. Congenital absence of the color 
sense (by no means a rare occurrence) will render 
nugatory the tests with candle and colored glass in 
diplopia. ; in such cases the test must be by the use 
of prisms. 

For details in the method of examination in the 
foregoing the student is referred to works on oph- 
thalmology. 

Optic neuritis or papillitis is an inflammation of 
the head of the optic nerve or disk. It is char- 
acterized by swelling, oedematous and inflammatory, 
lessened transparency of the tissues, with extension 
of the swelling to some distance beyond the limits 
of the disk. The edge of the disk loses its sharp- 
ness, becomes softened or " woolly" in outline, and 



V 



Fig. 25. 

Ophthalmoscopic appearance of choked disk. From 
Gowers. 



1 86 THE CRANIAL NERVES. 

over the steep edge the vessels can be seen to de- 
scend. The veins are swollen and tortuous, the ar- 
teries narrow, and both disappear in places, being 
covered by the swelling. The general tint of the 
swollen papilla is reddish and striated. The term 
" choked disk" is given to the condition, but the 
term is misleading as implying a definite mode of 
origin, which, indeed, is now admitted to be not due 
to constriction or to pressure of fluid within the sheath 
of the nerve. 

Neuro-retinitis (descendens) is believed to origi- 
nate in the nerve or centres behind, but its ophthal- 
moscopic appearances differ from those of papillitis 
in being without any considerable swelling of the 
disk, and the uniform redness of the disk passing un- 
changed into that of the retina. Papillitis has swell- 
ing of at least § mm. equalling 2 dioptres of re- 
fraction. 

The most frequent cause of papillitis is brain 
tumor ; it also occurs with meningitis, abscess of 
the brain, sinus thrombosis, and occasionally in hydro- 
cephalus internus, after acute infections diseases, and 
rarely during amenorrhcea and anaemia. 

The trouble is generally bilateral, but occasion- 
ally it is unilateral even when of central origin; 
unilateral optic neuritis is most frequently due to dis- 
ease of the nerve at the back of the orbit, or at the 
optic foramen. 

Prognosis of papillitis is largely a matter of diag- 
nosis of its cause. When due to anaemia or amenor- 



THE CRANIAL NERVES. I 87 

rhoea, the chances of cure are fair, especially as in 
these cases it advances rapidly and is apparently not 
accompanied by the destructive changes in the nerve 
which occur in the slowly advancing degeneration set 
up by brain disease. In any case, remedies must be 
addressed to the whole condition. 

Papillitis, if unchecked, advances to consecutive 
atrophy of the nerve. This consecutive atrophy does 
not differ in appearance from that known as secondary 
atrophy, due to compression of the nerve behind the 
bulbus. In both cases the disks are usually of the 
brilliant whiteness of tendon ; with the former, how- 
ever, there may be white spots outside the disk in 
the region of the macula. 

Primary atrophy of the optic nerve is seen in asso- 
ciation with central degenerative disease of the nervous 
system, such as locomotor ataxia or dementia paralytica. 
Here the disk is generally of a bluish-gray or at times 
of a light muddy tinge. The atrophy accompanying 
multiple sclerosis is most marked in the temporal 
halves of the disks and is generally white. 

Toxic influences, such as alcohol, tobacco, lead, bi- 
sulphide of carbon, mercury and (recently reported) 
Filix mas have caused atrophy of the nerve, in 
some instances preceded by papillitis. Such cases be- 
long to the ophthalmologist, but are mentioned here 
as offering suggestions in the selection of remedies. 
The writer has used Carboneum sulphuratum 6, and 
fluid extract of Filix mas in 6th dilution in the 
nope ot arresting the primary atrophy seen in lo- 



I 88 THE CRANIAL NERVES. 

comotor ataxia and dementia paralytica, but without 
result. 

Functional amblyopia occurs in hysteria and in at- 
tacks of migraine, with concussion of the brain and 
after profuse haemorrhage. 

Temporary hemianopsia may be present in migraine. 

Irritable retina is found in neurasthenia, hysteria, 
from excessive use of tobacco ; it may follow exposure 
to very bright light or the reverse. The use of 
smoked glasses to protect the eyes is unadvisable 
under ordinary circumstances, the retinal hyperes- 
thesia being thereby increased. 

The treatment of functional amaurosis or amblyopia 
must be largely that of the underlying neurasthenic 
or hysterical condition, or according to the cause, if 
any can be found. 

At the New York Ophthalmic Hospital the reme- 
dies most used for neuro-retinitis are Belladonna, 
Kalmia, Macrotin, Nux vomica. Phosphorus, Plumbum 
metallicum and Pulsatilla — all in low dilution, gene- 
rally 3x. Duboisia, Mercurius corrosivus and Veratrum 
album have been used less often. Pulsatilla has been 
found to be especially valuable in choked disk. 

In Dr. Rounds' Clinic at the above named institution 
a case of optic nerve atrophy from abuse of tobacco 
and alcohol, without perception of light, has been 
so far improved under the action of Agaricus — 15 
drops of the tincture three times a day — in 18 
months that he is now able to walk the streets 
alone. A nephew and a son of this patient had the 



THE CRANIAL NERVES. 1 89 

same trouble, but refusing or being unable to stop 
using alcohol and tobacco have not improved. In all 
three cases the disk was brilliantly white. 

The third nerve. This nerve, unfortunately termed 
oculo-motorius, arises from groups of cells placed be- 
neath the floor and somewhat to the side of the 
aqueduct of Sylvius. The fibres pass downward and 
coming together emerge from the inner face of the 
crus in front of the pons. 

From the occurrence of isolated palsies of eyeball 
muscles, experiments on animals and post-mortem 
examination (microscopical), it is held that each eye- 
ball muscle is innervated by fibres from a definite 
group of cells. The arrangement of the groups as 
given by M. Allen Starr is the following : 

Sphincter iridis Ciliary muscle g 

Levator palpebral Internal rectus "^ 

Superior rectus Inferior rectus ^ 

Inferior oblique g 

In the middle line beneath the aqueduct is a cen- 
tral group of cells, while from the so-called posterior 
nucleus fibres are given off that pass into the nerve 
of the opposite side. This decussation is believed to 
concern the internal recti, whose action in convergence 
is distinct from the isolated action of one internal 
rectus. 

The fourth nerve arises from a group of cells pos- 
terior to the third nerve nucleus. The fibres pass 
backward and upward to emerge as a nerve trunk 
behind the posterior quadrigemina and cross over the 



190 THE CRANIAL NERVES. 

middle line to wind around the opposite cms and 
appear at the base. 

The sixth nerve which, for convenience sake, had 
better be considered here, arises from the cells of 
its nucleus situated beneath the floor of the fourth 
ventricle. The fibres pass downward and emerge next 
to the middle line and behind the posterior border of 
the pons. 

The muscles supplied by the third nerve are already 
given in the table. The fourth nerve supplies the 
superior oblique, the sixth the external rectus. 

The actions of the eyeball muscles are indicated in 
most of them by their names ; the internal rectus 
turns the eyeball inward or toward the nose, the 
external rectus turns it outward or towards the tem- 
ple, the superior rectus turns it upward; the inferior 
rectus turns it downward; the oblique muscles act 
similarly to their opposite named recti — thus the 
superior oblique turns the eyeball downward, the in- 
ferior oblique turns it upward, while both obliques 
turn it somewhat outward, and both superior and 
inferior recti turn it somewhat inward. 

In turning both eyes to the right or to the left 
there must be an associated action of the internal 
rectus of one eye with the external rectus of the 
other. Cases occur in which with a paresis of the 
external rectus of one side the internal rectus of the 
other side is inactive in binocular vision, but if the 
first be covered the internal rectus of the second 
acts perfectly. From this it is inferred that the sixth 



Q^ 


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t 


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* 


-%. 


♦ 


♦ 


♦ 






♦ | ♦' 


•^ 


_J&- 


— ♦ 


♦ 


♦ 


♦ 



Nervus oculomotoruLS 



♦ 1 ♦ 



♦ ♦«; ♦* 







Muse oblu/wis infei wr V^ 


♦'♦ 


* 


4 




♦ 


4 


♦ 


sAbducens. / 


"V / 


# # 


♦♦1 


♦ 





MuscAreetus superior 



y 

^^ tfntcrmis. ^_ 


♦ 




• ^ 


^ 


W 


+ * 


/ ^% -> 




♦ 


4 


♦# 



Muse troc7deeiris . 


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4 


4 


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4 


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^J/zZ.?C^ 


rectus inferior. 


♦ 


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V" 


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Nervus oculomotor -ius . g 



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Fig. 26. 
Fig. 26. From Roth. In the illustration of diplopias resulting from paralysis ot different muscles 
of one eye, each large square represents the binocular visual held, subdividedas tollows : 



UPPER OUTER 


UPPER 


UPPER INNER 


OUTER 


DIRECTLY IN FRONT 


INNER 


LOWER OUTER 


LOWER 


LOWER INNER 



The reader sees the double images in the drawing as if his own left eye were affected. To make 
the drawing represent paralysis of a muscle of the right eye he must represent himself as being in 
front of the patient and mentally view the double images from that position. 

The perpendicular meridian of the cornea is indicated by a thick black line. 

The arrows indicate the direction of action of the different muscles, their insertions at the cornea 
showing also the rotatory action of the muscles. 

The arrows marked OCUlomotoriUS point to the resulta influence of the action of all the 
muscles supplied by the third nerve. The components are separated by the pinterolated drawing 
showing the diplopia from isolated paralysis cf the internal rectus. 

The figures in black represent the true images, those with cross-lines the so-called false images of 
the affected eye. 

The dotted lines within the larger squares are lines of separation between single vision with both 
eyes and double vision. 

To compare the statements of a patient (looking at a lighted candle with both eyes, a red glass 
being held before one), the examiner should be behind the patient if the left eye is affected, but in 
front of him if the right eye. On mapping out the double images as stated by the patient these double 
images will agree in either case with those as given by Roth. 



192 THE CRANIAL NERVES. 

nerve nucleus is connected with the sub-nucleus of 
the third for the internal rectus of the other side. 
The sixth nerve nucleus thus acts as the centre 
for the conjoined action of both eyes in lateral 
movements of the eyes, and the connection be- 
tween the two nuclei is held to be via the pos- 
terior longitudinal bundle or fasciculus, a bundle of 
nerve fibres passing down from the region of the 
third nerve nucleus to the lower part of the medulla. 

Conjugate deviation of the eyes to one side is a 
symptom of high value if correctly interpreted. It 
may be due to a cortical or sub-cortical lesion, or 
to a pontine one ; in either case it may be para- 
lytic or irritative. A paralyzing lesion in the cere- 
brum may cause besides hemiplegia paralysis of the 
opposite sixth nerve with associated inaction of the 
internal rectus on the side of lesion. Hence there 
then will be conjugate deviation of the eyes to the 
side of the lesion. If the lesion be an irritative one 
the opposite sixth nerve nucleus overacts, and with it 
the internal rectus of the side of the lesion. There 
is then conjugate deviation from the side of the le- 
sion. "The patient looks towards the convulsed mem- 
bers if there is irritation ; he looks towards the le- 
sion if it is a paralyzing one." (Landouzy, Grasset.) 

The rule is reversed in the case of a pons lesion 
causing conjugate deviation of the eyes. 

The Pupil. The pupil is the circular aperture in 
the iris. The iris is a muscular curtain separating the 
anterior from the posterior eye-chamber. It is com- 



PUPIL. 193 

posed of circular fibres termed collectively the sphincter 
pupillse, which are innervated by a branch of the third 
nerve, and radiating fibres forming the dilator pupillse 
under control of the sympathetic. 

The two sets of fibres are antagonistic and their 
combined action is to regulate the size of the pupil 
and hence to regulate the amount of light entering 
the eye. 

When an increase of light falls upon the retina, 
besides the sensation transmitted to the occipital cortex 
an impulse is also sent through the optic nerve to the 
anterior pair of the corpora quadrigemina, each corpus 
receiving such impulse from both eyes. From the cells 
of the anterior corpus a new impulse is sent to the 
anterior part of the third nerve nucleus below, from 
which in turn a motor impulse is sent to the sphincter 
pupillae, with consequent contraction of the circular 
fibres, and hence diminution of the size of the pupil. 
Lessening of the amount of light entering the eye acts 
negatively by lessening the demand on the third nerve 
nuclei, and then the tonus of the dilator fibres antago- 
nizes the now passive sphincter, and the pupil dilates. 
The fibres or connections between the anterior corpora 
bigemina and the third nerve nuclei have not as 
yet been anatomically demonstrated. Since both an- 
terior corpora receive the light-impulses for pupillary 
action from each eye, it can readily be understood 
why both pupils must normally be of the same size, 
even if light be admitted to one eye only. 

When the visual axes are made to converge, as in 



194 THE CRANIAL NERVES. 

accommodating for near objects, the pupil contracts in 
associated action ; when accommodation is relaxed the 
visual axes become more nearly parallel and the asso- 
ciated action of the sphincter pupillse ceases, and the 
pupil dilates. Hence in testing pupillary activity under 
the stimulus of light, the subject must be made to 
look at a distant object, 10 feet away, if possible. 

From the foregoing it is plain that alteration in 
the actions of the pupil, apart from adhesions of the 
iris, etc., must be due either to an affection of the 
third nerve or its nucleus or its cortical area, or a le- 
sion involving the connection between the anterior corpus 
and the third nerve nucleus, or else to the sympathetic. 

Irritation of the sympathetic fibres for the iris causes 
dilatation of the pupil ; paralysis of these fibres causes 
contraction through the now unopposed action of the 
sphincter. Test for the unimpaired action of the sym- 
pathetic supply to the iris is made by stroking sharply 
or pricking or faradizing the skin at the side of the 
neck ; dilatation of the pupil of the same side then 
occurs if the sympathetic supply is unaffected. The 
reflex is known as the pupillary skin reflex. 

In facial neuralgia, in migraine, in some forms of 
headache, with chronic disorders of the teeth, etc., 
the pupil of the affected side may be altered as to 
size. Even affections in distant parts (mediastinal 
tumor) may so affect the sympathetic nerves as to 
alter the size of the pupil of the same side. 

When the radiating fibres are contracted (irritation 
of the sympathetic) to a high degree, the pupil is 



PUPIL. I95 

dilated, but some contraction is possible under the in- 
fluence of light and in accommodation. 

When the radiating fibres are paralyzed (paralysis 
of the sympathetic) the pupil is moderately contracted, 
but can contract still further under the influence of 
light and accommodation. 

When the sphincter is paralyzed (third nerve) the 
pupil is dilated, but contraction under the influence 
of light and accommodation does not occur. The 
skin reflex is, of course, not affected, and the action 
of atropine, which besides paralyzing the sphincter 
also irritates the radiating fibres, increases the dilata- 
tion ad maximum. Duboisine, hyoscyamhie and many 
other mydriatics act in the same way. 

Spasm of the sphincter causes marked narrowing of 
the pupil, which is immobile under the influence of 
light and accommodation or even the skin reflex, the 
sphincter fibres being more powerful than the dilator 
ones. E serine increases in such cases the myosis by 
irritating the sphincter and paralyzing the radiating 
fibres. Pilocarpine, muscarine and nicotine act simi- 
larly. 

When only one set of fibres is paralyzed, the un- 
opposed action of the other set results in its contrac- 
tion, which increases by continuance, so that in course 
of time the dilatation from third nerve paralysis, for 
instance, becomes greater than at first. 

Paralysis of both sphincter and dilator fibres causes 
moderate dilatation, with immobility of the pupil (ca- 
daveric position). 



I96 THE CRANIAL NERVES. 

The reaction of the pupil under the influence of 
light upon the retina may be lost, while the asso- 
ciated action in accommodation and convergence is 
retained. This is known as the Argyll- Robert son 
pupil, and is found in disease affecting the central 
gray below the aqueduct of Sylvius, the sub-nucleu& 
for accommodation and convergence escaping. The 
condition is often present in locomotor ataxia. 

Spinal myosis is the term given to loss of the 
sympathetic influence in the same disease ; when 
present, the pupil is contracted often to the size of a 
pin-head, and may or may not have the character of 
the Argyll-Robertson pupil. 

It must be remembered that in elderly persons 
the pupil becomes small, and its reactions slow 
or nearly disappear; the skin reflex shows the loss 
first. Dilated pupils in the old are pathological, 
whether from local ocular trouble or from nervous 
disease. On the other hand, contracted pupils in 
persons under fifty must be interpreted in a similar 
way. 

The Ophthalmoplegias. The word ophthalmoplegia 
is used to indicate paralysis of the eye muscles. When 
only the external muscles of the eye are affected it 
is called ophthalmoplegia externa, when only the 
muscles within the eye are involved it is o. interna ; 
o. partialis and o. totalis indicate respectively paralysis 
of some of the muscles and of all. 

The source of paralysis of an eye muscle may be 
a lesion of the related nerve within the orbit or in 



OPHTHALMOPLEGIAS. 1 97 

its course after emerging from the brain, or between 
the latter point and its nuclear origin, or finally in 
the nucleus itself. In any case the affection may be 
acute or chronic. 

When a muscle whose function is to turn the eye- 
ball is paralyzed, the eyeball can no longer be directed 
as formerly by the normal activity of the muscle, and 
the eye lags behind its fellow when the attempt is 
made to view an object lying in such direction. As 
a result the rays of light from the object do not fall 
upon the yellow spot of the affected eye, as in the 
normal eye, and two images are seen, because for the 
production of one image in binocular vision the visual 
axes must be so directed that rays from the object fall 
upon the same parts of the two retinas. 

If, for instance, the affected eye be unable to turn 
outward, then in any effort to look in that direction the 
eyes are crossed, but the image seen by the affected 
eye is apparently still further in the direction in 
which the vision has been directed. For, as the rays 
of light cross in entering the eye it is plain that 
objects situated higher than the pupil must affect 
the lower segments of the retina. The brain has 
learned by experience to associate impulses received 
by the lower portion of the retina with objects situ- 
ated above the eye ; similarly, impulses received from 
the upper portions of the retina are recognized as 
being made by rays from objects below the pupil, 
those from the left half of the retina and those from 
the right half representing objects in the opposite 
lialf of the visual field in each case. 



I98 THE CRANIAL NERVES. 

The importance of correctly determining the position 
of the image seen by the affected eye both absolutely 
and in relation to that seen by the unaffected one, is 
so great in the examination of certain forms of nervous 
disease that study of the figure reproduced from A. 
Roth is urged upon the reader. 

When only one of the ocular motor nerves is para- 
lyzed, the inability of the affected eye to follow 
the examiner's finger to the normal limit in some 
one direction will permit of a ready diagnosis. 
When two nerves are affected the same method will 
apply ; when all three nerves are paralyzed the im- 
mobility of the eyeball will make the fact plain; a 
paretic state of the muscle or muscles may not show 
when tested as above directed, but yet may give 
double images under the test with candle and colored 
glass. 

The causes of ocular palsies are chiefly rheumatic 
influences (cold) and syphilis directly affecting the 
nerve or indirectly causing pressure from gummy 
meningitis at the base. Diphtheria not infrequently 
is followed by paralysis of one or more eye muscles, 
usually the iris and ciliary muscle, more rarely the 
internal recti as well. In locomotor ataxia, abnormal- 
ities in the action of the muscles of the eye are quite 
frequently seen ; in the early stages these paralyses 
are usually temporary. 

Complete paralysis of the third nerve results in loss 
of power in the internal, superior and inferior recti, 
inferior oblique, the ciliary muscle, the circular fibres 



OPHTHALMOPLEGIAS. 1 99 

of the iris and the levator palpebral When the fallen 
upper lid is raised, it is seen that the eyeball cannot 
move except outwardly and also downward and out- 
ward. The pupil is dilated but not ad maximum; it 
does not react reflexly to light nor in the effort at 
accommodation, the latter faculty being of course absent. 
The eyes are divergent, but the diplopia is crossed. 
Only a part of the third nerve supply may be affected; 
hence at times a single muscle only is paralyzed. A 
slight ptosis may be caused by paralysis of the sym- 
pathetic, the fibres of Mtiller's muscle thereby be- 
coming paralyzed; at the same time the dilator fibres 
of the iris being paralyzed, the unopposed action of 
the sphincter causes contracted pupil. 

Hysterical ptosis occurs, usually with associated 
spasm of the orbicularis ; and a functional ptosis 
noticed on waking in the morning is sometimes ob- 
served, which soon passes off. 

Paralysis of the fourth nerve is not often seen. The 
resulting diplopia is in the lower and outer half of 
the field and is especially annoying in walking, de- 
scending stairs or when at work. Downward move- 
ment of the eye can be made, but then the eye turns 
somewhat inwards so that the visual axes cross and 
the diplopia is therefore homonymous. 

Paralysis of the sixth nerve occurs next in frequency 
to that of the third. The visual axes are crossed and 
the diplopia is homonymous. 

Nuclear Ophthalmoplegia. Under the title polio- 
encephalitis superior acuta (in contrast to p. inferior, 



200 THE CRANIAL NERVES. 

one of the bulbar affections) Wernicke has described 
a disease, acute in onset and rapid in course. Be- 
ginning with headache, vertigo and vomiting, delirium 
or it may be somnolence, occurs, and at this time 
paralysis of the muscles of the eye appears; in some 
instances almost total ophthalmoplegia was finally mani- 
fest, the sphincter iridis and levator palpebrae being 
unaffected. Neuritis optica occurred in some cases 
and ataxic gait, similar to that of cerebellar disease, 
was noted. No increase of temperature was recorded, 
but the pulse was usually rapid. 

Most of the cases have ended fatally within a week 
or two. 

Post-mortem examination revealed an acute hsemor- 
rhagic encephalitis of the central gray at the floor 
of the third ventricle and beneath the aqueduct of 
Sylvius. 

The cause assigned in the early cases is chronic 
alcoholism ; later, cases have occurred after infectious 
diseases, especially influenza, from poisoning by spoiled 
sausage, by carbon monoxide and by nicotine. 

Progressive nuclear ophthalmoplegia as an inde- 
pendent affection is rare; as an accompaniment or part 
of some organic disease of the nervous system it is 
not infrequent, especially in bulbar paralysis, locomotor 
ataxia, dementia paralytica and progressive muscular 
atrophy; it has also been observed in multiple sclerosis 
and in combined system-disease of the spinal cord. 

The disease is gradual in its onset, in most 'cases 
a slight ptosis with some diplopia being the earliest 



NUCLEAR OPHTHALMOPLEGIA. 201 

symptoms. With the progress of the disorder, other 
muscles are involved gradually. The interior muscles 
of the eyes escape in most cases, so that the af- 
fection is generally an ophthalmoplegia exterior bi- 
lateralis. 

The prognosis is unfavorable for cure ; the disease 
process may extend over many years, but it may 
cease to advance. The danger to life becomes 
greater when the process seizes the motor nerve 
nuclei in the medulla, or when it is a part of pro- 
gressive muscular atrophy. 

Anatomically, the disease is a chronic inflamma- 
tory or degenerative process in and about the ocular 
nerve nuclei beneath the floor of the aqueduct of 
Sylvius, the anterior sub-groups for the innervation of 
the ciliary muscles and the sphincters of the irides ap- 
parently escaping in most of the cases. The syphil- 
itic process can affect the same region ; such cases 
may improve under treatment. In multiple sclerosis 
the nuclei are not affected, as a rule, but the nerve 
roots are the seat of the trouble (Oppenheim). 

Treatment should be that of the associated dis- 
ease, but as the latter is frequently initiated by the 
former, the treatment then must be symptomatic. At 
the New York Ophthalmic Hospital, Agaricus, Gehemium 
and Physostigma are favorite remedies in paralysis of 
eyeball muscles. Causticum and Conium are especially 
indicated in isolated ptosis and in paralysis of the 
ciliary muscle. 

When the affection is even probably nuclear, Sypli- 



202 THE CRANIAL NERVES. 

ilinum high, Plumbum and Carboneum sulphur atum 
should be studied, while if the trouble be part of 
a more extensive degenerative process, the remedies 
applicable in the latter may find place here. Cases 
undoubtedly syphilitic will require Merc. jod. flav. y 
low, and if gumma be suspected it must be removed 
by the solvent action of iodide of potassium in ma- 
terial doses. 

Other remedies that have proven valuable in treat- 
ing paralytic eye muscles are Bhus tox. and Arnica, 
prescribed on rheumatic or traumatic indications, 
Jaborancli, Natrum mur., Nux vomica, Senega and Sul- 
phur. Euphrasia and Phosphorus have cured when 
indicated by accompanying special symptoms or condi- 
tions. In all cases the remedy should be sought for 
by studying the known indications of the different 
drugs. 

Recurrent or periodical oculo-motor paralysis is 
a somewhat rare affection with some peculiar features 
that led Charcot to give it the name ophthalmo- 
plegic migraine. It usually begins in youth or early 
childhood, in one case at the age of 11 months. The 
attack may be divided into two parts. First, severe 
pain in, around and. behind the eye of one side with 
headache of the same side and vomiting. These 
symptoms continue for a day or two, a week, or even 
three or four weeks (Mobius), and they cease with 
the occurrence of the paralysis, which may affect all 
the muscles sirpplied by the third nerve. Occasion- 
ally the external rectus has been affected. The pa- 



RECURRENT OCULO-MOTOR PARALYSIS. 203 

ralysis lasts perhaps a few days, perhaps many 
months, but seems to be in direct relation to the 
length of the sensory part of the attack. The 
attacks return at definite intervals, in some cases 
a week, in others a month, in others six months, 
in some patients always at a menstrual period, 
and so on. In those having frequently recurring 
attacks, these are shorter. In the intervening 
time most of the paralytic symptoms slowly dis- 
appear, but partial ptosis or weakness of the 
pupillary reflex may remain after all other symp- 
toms have gone. The intervals become less as years 
go on and the paralytic symptoms more permanent. 
The disease seems to be related to migraine, yet 
has positive differences from it. Migraine is at times 
accompanied by ocular palsies, but these are seen 
in the beginning of the attack, not after cessation 
of pain. With migraine there is in most cases in- 
heritance, in the present disease none. Yet the pres- 
ent trouble is migrainous in its sensory manifesta- 
tions. No satisfactory hypothesis of its origin has as 
yet appeared. 

The treatment ought to be, in the first part of the 
attack, that for migraine ; in the second part, that 
for paralysis of the third nerve. But the best results 
will be obtained by placing the patient under treat- 
ment during the interval and using, as they may be 
indicated, our great antipsorics. 



204 THE CRANIAL NERVES. 

Insufficiencies and other abnormalities of the ocular 
muscles have been assigned as causes of certain ner- 
vous affections, such as epilepsy, migraine, headache, 
chorea, facial and other spasm, vertigo and even 
organic nervous disease. Discussion of the subject 
has been extensive during more than a decade and 
repetition of it is out of place in this book. That an 
inborn insufficiency of some muscle of the eye can, in 
course of time, set up in a neurotic person many 
symptoms of nervous trouble may not now be doubted, 
but that post hoc means propter hoc in all cases in 
which graduated or other tenotomies were followed by 
relief, is not the writer's opinion. 

Uncorrected errors of refraction may undoubtedly 
give rise to headache and other nervous trouble. 

In either case of eye strain the concomitant nervous 
disorder may not be amenable to remedies until the 
ocular defect is removed or corrected. 

Special treatment for the ocular conditions just men- 
tioned belong properly to the ophthalmologist. 

The fifth cranial nerve or trigeminus apparently 
emerges by two roots from the side of the pons. Its 
origin is analogous to that of a spinal nerve for the 
posterior or sensory root originates, in the Grasserian 
ganglion, the cells of which give rise to the peripheral 
fibres and to the post ganglionic, afferent or sensory 
root. The fibres of the latter enter the pons and turn 
downward, ending each in a brush-work around the 
cells of the gelatinous substance in the medulla and 
upper cervical cord. In cross sections of the medulla 



THE CRANIAL NERVES. 205 

and upper cervical cord the fibres can be seen as a 
compact mass, a mere fringe outside the substantia 
gelatin osa at the level of the decussation of the pyra- 
mids, but as a large kidney-shaped bundle in the pons. 
Until recently it was termed the ascending root of the 
fifth. 

The motor root ot the fifth cranial nerve is divisible 
into a larger, the motor root proper, and a smaller root 
considered by Kolliker to be also motor, by others to 
be trophic in function. The latter arises from cells 
not aggregated into a nucleus, and placed at the outer 
limit of the gray matter around the aqueduct. The 
fibres from them can be seen in all sections as far 
down as their place of exit from the pons. They are 
called the descending root of the fifth. The dis- 
tribution of the fibres is not known. 

The motor root proper arises from the motor nucleus 
situated within the pons. Its fibres pass forward be- 
neath the sensory fibres and their ganglion and are 
distributed to the masseter, the two pterygoids, mylo- 
hyoid, anterior belly of the digastric, the temporal 
muscles and tensor tympani. The motor root receives 
some fibres from the nucleus of the opposite side. 

The trigeminus is the sensory nerve of the face as 
far back as the ear and as low as the lower outline 
of the lower jaw, of the scalp as far back as the 
crown, of the mouth and its contents, including the 
teeth, soft palate and uvula (but not the extreme base 
of the tongue); the antrum and the frontal sinus, part 
of the external auditory canal and the greater part of the 



206 THE CRANIAL NERVES. 

membrana tympani. The dura mater, which is the 
only sensitive membrane, is supplied by this nerve, 
except in the occipital region and the posterior fossa, 
and the tentorium and the falx are innervated by it. 

The four ganglia situated on different divisions of 
the nerve are of some importance in connection with 
the sympathetic fibres which it receives; they subserve 
trophic, vasomotor and secretory functions. 

The cortical area is unknown, but its sensory re- 
presentation is probably in the parietal cortex, its 
motor representation being probably in the lower 
portion of the central convolutions of the opposite 
hemisphere. 

Neuralgia of the fifth cranial nerve has been al- 
ready considered under Neuralgia. 

Trophic changes, such as herpes, in the distribution 
of the nerve are seen at times during an attack of 
trigeminal neuralgia. Herpes may be extensive and may 
affect the mucous membrane lining the mouth and 
give rise to additional pain in eating. Its cause is con- 
sidered to be irritation of the Gasserian ganglion. 

Paralysis of the nerve may occur from injury or 
from pressure by a tumor at the base. The result is 
anaesthesia throughout the distribution of the nerve, 
with paralysis of the muscles supplied by it. Chew- 
ing is done by the muscles of the opposite side, whose 
pterygoids carry the jaw toward the affected side. If 
irritation of the Gasserian ganglion be present, herpes 
of the cornea, followed by keratitis neuroparalytica (so- 
called) may be a result. 



PROGRESSIVE FACIAL HEMIATROPHY. 207 

Treatment of such affections of the fifth nerve must 
be that of the underlying cause. 

Progressive Facial Hemiatrophy. 

A rather rare affection, characterized by wasting of 
the skin, subcutaneous tissues, bones, and at times 
the muscles of one side of the face. The affection 
develops usually between the tenth and twentieth years, 
and more frequently in girls. No cause is assignable in 
many cases, but in some, undoubted history of trauma 
at the affected site or a preceding infectious disease, can 
be obtained. The disease may show first at some one 
region, such as the neighborhood of the orbit. The 
skin becomes thinner and whiter (loss of pigment) or 
else becomes yellowish or brown (excess of pigment), 
the hair becomes finer, and later falls out. The sub- 
cutaneous connective tissue disappears and the skin 
becomes wrinkled. The disappearance of fatty and 
connective tissue from the bottom of the orbit permits 
the eyeball to sink and then the palpebral fissure be- 
comes narrower — the eye appearing smaller than its 
fellow of the other side. The disease is slow in pro- 
gress and when the bones are much involved, the 
asymmetry of the face becomes very striking. When 
the affection does not begin until adult age, the bones 
are but rarely attacked. The masseter muscles usually 
escape, but the muscles of the tongue are at times 
wasted. The electrical reactions in the affected mus- 
cles are not altered. The functions of the skin may be 
altered, the sebaceous secretion being lessened, while 



208 THE CRANIAL NERVES. 

secretion of sweat may be greater; the power of 
blushing may be lost on the affected area. Anaesthesia 
is not present as a rule, but pains in the distribution 
of the fifth nerve may precede the appearance of the 
atrophy. The disease progresses to a certain point 
and then ceases to advance. It has been seen as a 
complication of other nervous diseases and a similar 
atrophy in the arm may accompany it. 

The pathology of the disease as ascertained by Men- 
del is, that it is due to a neuritis of the fifth nerve 
with degeneration of its so-called descending root. 

Treatment of such cases as have apparently followed 
trauma, has some hope. In one case where the affec- 
tion began soon after a blow beneath the eye, the 
trouble was arrested, arnica being given among other 
remedies, and galvanism used. The current was given 
stabile, the negative pole, an insulated carbon elec- 
trode, being placed upon the atrophied masseter muscle 
inside the cheek. The patient was under treatment 
several months and now, after the lapse of some 
years, the asymmetry of the face is hardly noticeable. 

The facial or seventh cranial nerve is made up 
of the neuraxones of the cells of the facial nucleus 
in the pons. The fibres pass, while still within 
the pons, inward and upward, curving around the 
nucleus of the sixth nerve to pass downward and 
outward, finally emerging at the lower edge of the 
pons between the olivary and restiform bodies of the 
medulla. It enters a bony canal in the temporal 
bone, where it is joined by the chorda tympani 



PERIPHERAL FACIAL PARALYSIS. 20g 

given off from the lingual branch of the fifth, and 
finally emerges at the stylo-mastoid foramen. 

The facial nerve is the motor nerve for the mus- 
cles of the face, the platysma, the stapedius and the 
stylo-hyoid muscles. 

The chorda tympani carries taste fibres,* which 
after joining the facial probably leave it by the great 
petrosal to once more become part of the fifth. 

The facial area in the cortex is in the lower part 
of the motor area, and chiefly of the anterior cen- 
tral convolution. The fibres from its cells pass 
inwards to the internal capsule, and take the most 
inward position in the motor tract, which position 
they hold in the pes of the cms. At the beginning 
of the lower third of the pons they cross and end 
at the nucleus of the facial nerve. They are the 
first fibres of the motor tract to decussate, and so 
furnish means for an important difference in diag- 
nosis between a cortical lesion and a lower pons 
lesion. 

Peripheral Facial Paralysis.— Bell's Palsy. 

The facial nerve being wholly motor in function (ex- 
cept that in part of its course it carries taste fibres from 
the lingual nerve which leave the trunk via the great 
petrosal nerve), disease or injury to the nerve is shown 



* There is much reason for holding that the sense of taste is carried by the fifth 
cranial nerve (lingual branch) chorda tympani, great petrosal and the second di- 
vision of the fifth (but individual differences exist) from the anterior two-thirds of 
the tongue, and that the posterior third is subserved by the ninth or glosso- 
pharyngeal. Both nerves are nerves of common sensation also. 



2IO THE CRANIAL NERVES. 

by paralytic symptoms in the muscles of the face. 
Such paralysis differs from paralysis of the face of 
cerebral origin ; in the latter case the upper part of 
the facial distribution is usually not affected, the nerve 
supply through the trunk of the facial not arising from 
the cells of its nucleus, but from some higher source, 
and not forming part of the motor tract. Hence in 
a hemiplegia the orbicularis oculi, the temporal and 
the corrugator muscles are not paralyzed. 

Peripheral facial paralysis most commonly results 
from exposure to cold and especially to the local influ- 
ence of a draught of air upon the face. It also occurs 
in ear disease, from injuries to the region of the ear 
and from accidental section of the nerve in operation 
on the parotid gland. It has been recorded as part 
of multiple neuritis and in locomotor ataxia and at 
times in the infant from pressure of the forceps during 
delivery. 

The symptoms appear within a few hours or a day 
or two after exposure, preceded at times by pain in 
the region of the ear (local implication of the fifth 
nerve). The most marked objective symptom is the 
inability to close the eye of the affected side ; even 
the ordinary winking reflex is gone. The forehead 
cannot be wrinkled, nor the eyebrow brought to the 
middle line, as in frowning. The angle of the mouth 
on the affected side is lower than its fellow of the 
opposite side ; in blowing, the air escapes from this 
angle of the mouth instead of the middle. In chew- 
ing, the food cannot be properly moved and accumu- 



PERIPHERAL FACIAL PARALYSIS. 211 

lates between the teeth and the cheek from loss of 
power in the muscles of the latter. The dilator 
muscle of the nostril of the affected side being para- 
lyzed, that nostril is narrower than its fellow. The 
lower lid not being in close apposition to the eyeball, 
the tears do not get into the lachrymal canal and may 
overran the cheek, giving rise to redness and irritation; 
the eyeball being always uncovered (even during 
sleep) it is not kept free from minute particles, which, 
together with evaporation, tend to set up irritation 
or even inflammation of the conjunctiva. 

The course of the nerve, its association for a short 
distance with the eighth nerve, its own branches (es- 
pecially the chorda tympani) permit of fine topo- 
graphical diagnosis as to the site of the lesion, which 
is valuable for the prognosis. Between the junction 
of the chorda tympani below and the geniculate gang- 
lion above, run the taste fibres. A lesion in the lower 
part of the bony canal or after emergence of the nerve 
from it, is not accompanied by loss of taste. A lesion 
higher up in the canal may have temporary loss of 
taste with lessening of the salivary secretion and hence 
dryness of the mouth. 

Rheumatic forms of facial paralysis are generally 
peripheral and relatively slight in degree. The elec- 
trical reactions of both nerve and muscles are not 
changed, and rapid cure (within a few weeks) is to 
be expected. When the nerve at the end of two 
weeks shows a lessening but not complete loss of 
reaction to galvanism, while the muscles give slow 



2 1 2 THE CRANIAL NERVES. 

contraction to direct application, without reversal of the 
formula, there is partial RD, and favorable prognosis 
of cure within three or four months may be given. 

When complete ED of nerve and muscles is shown 
by the electrical tests, cure may occur in a few months 
or perhaps not at all. 

If the lesion is due to ear disease, disease of the 
bone, etc., cure cannot take place until such disease 
ceases. If the originating cause was section of the 
nerve (operation, or other injury) a secondary operation 
to suture the divided ends together will be necessary 
before restoration of function can be effected. 

In severe cases, after some months, secondary con- 
tractures affect the paralyzed muscles, the mouth being 
drawn up on the paralyzed side, and, to a casual ob- 
server, the really unaffected side then appears to be 
the paralyzed one. 

Anatomically, Bell's palsy is due to degenerative 
peripheral neuritis of the facial nerve ; the symptoms 
may occur in bulbar disease (q. v.). Disease of the 
nucleus alone will not cause involvement of the muscles 
surrounding the eye. 

Gummy exudations at the base may involve the 
emerging fibres of the facial, but the auditory nerve 
will then hardly escape, and other and distant cranial 
nerves may be affected. The writer has reported a 
case of paralysis of the 3d, 5th and 7th nerves in a 
syphilitic ; here, while there was inability to close the 
eye completely, there was also partial ptosis. 

The homoeopathic treatment of Bell's palsy must 



PERIPHERAL FACIAL PARALYSIS. 2 I 3 

be guided largely by the causal indications. In the 
writers experience Rhus tox. and Dulcamara have given 
apparently good results. Causticum in one case and 
Cimicifuga in another acted similarly. Aconite, Bellis 
perenniSj Ruta grav. and Belladonna are remedies that 
ought to be thought of in the rheumatic form of the 
affection. Since many cases are light in degree and 
would probably get well of themselves, it will need 
many such recorded cases to enable us to say definitely 
just how much our remedies accomplish. 

In the cases that are symptomatic of some other 
disease as the cause, treatment for the latter is, of 
course, of the first importance. 

The employment of galvanism in facial paralysis is 
a routine matter with the writer. Patients seem to 
experience benefit from it. 

To protect the eye the writer instructs patients to 
close down the upper lid with the hand many times 
in the day and to sleep with a well-applied bandage 
over the closed lid. Further, patients should rub the 
paralyzed side of the face upward often during the 
day. 

In old persons, peripheral facial paralysis may be 
very intractable. 

Spasm in the distribution of the facial nerve will be 
considered with the spasmodic disorders. 

The eighth cranial nerve is the common trunk of 
two nerves, distinct in origin and in function. One 
arises in the ganglion cells of the ganglion spirale 
of the cochlea, from which fibres can be traced out- 



214 THE CRANIAL NERVES. 

ward to the cells of the organ of Corti and inward 
to the medulla. This is known as the cochlear nerve 
and is the real auditory nerve. 

The other arises from cells in the intumescentia 
ganglioformis Scarpa? or vestibular ganglion in the 
superior fossa at the bottom of the internal auditory 
meatus. Fibres go from the cells in two directions, 
in one to the vestibule and semi-circular canals, in 
the other to the medulla. This nerve is known as 
the vestibular nerve, or space-sense nerve, since it 
carries impulses from the semi -circular canals in 
which any change of position of the head results in 
alteration of the relation between the membranous 
duplicate of the semi-circular bony canals and the 
fluid within them. The two nerves while yet within 
the internal auditory meatus unite into a common 
trunk, which reaches the medulla and enters it by two 
divisions, the lateral and posterior one being the cochlear, 
the inner and anterior being the vestibular nerve. 

The greater number of the fibres of the cochlear 
nerve end amid the cells of the ventral or accessory 
acoustic nucleus, while a portion wind around the 
inferior peduncle of the cerebellum to reach the 
chief nucleus and Deiter's nucleus. 

The fibres of the vestibular root pass to the inner 
side of the ventral nucleus and reach the chief nu- 
cleus and Deiter's nucleus, amid the cells of which 
most of them end. 

From the ventral nucleus new fibres arise that 
cross in the raphe, pass into the lateral lemniscus in 



THE CRANIAL NERVES. 2 I 5 

part, in part to the formatio reticularis, arid end 
about the cells of the posterior corpus quadrigeminum 
and internal geniculate body, whence a new set of 
neurones begin, whose long fibres go to the cortex oi 
the temporal lobe. A part of the fibres do not cross, 
but pass up on their own side. 

Fibres from the chief nucleus and Deiters nucleus 
are sent to the cerebellum to end at the roof nu- 
cleus, or the emboliform and globose nuclei (Flech- 
sig) ; a part enter the formatio reticularis, or enter the 
raphe and get to the formatio reticularis of the other 
side ; another part crossing, enter the lateral lemnis- 
cus. The cortical area in relation to the vestibular 
nerve and its central tracts is unknown, but is placed 
by Bechterew in the parietal lobe. 

Irritation of the nervous structures in the coch- 
lea, or of the cells in the temporal lobes, will give 
rise to dysacusis, a condition in which ordinary 
sounds are perceived painfully, as seen during menin- 
gitis, headache, etc., and at times in hysterical states. 
Irritation of the same structures may also cause sub- 
jective sensation of sounds, as ^whistling, buzzing of 
insects, singing or ringing, etc. Such subjective sen- 
sation is termed tinnitus aurium. Its most frequent 
cause is aifection of the middle ear, circulatory dis- 
turbance, etc. It may be constant, and often is the 
basis of auditory hallucinations in the insane. 

Destructive changes in the auditory nerve or its 
end organs in the cochlea give rise to loss of hear- 
ing power, either total or partial. Affections of the 



2l6 THE CRANIAL NERVES. 

external and middle ear can give rise to deafness by 
preventing or interfering with the conduction of sound 
waves to the cochlea. Such deafness is to be dis- 
tinguished from nervous deafness by examination with 
the otoscope and head mirror, and by the use of 
the tuning fork. When a tuning fork is set in vi- 
bration and its handle applied to the mastoid process 
the bone will conduct the sound-waves to the cochlea 
under normal conditions. Under the same conditions 
when such perception of sound ceases, if the still vi- 
brating instrument be removed and held near the 
external auditory meatus, the sound will be perceived 
anew. Thus bone and aerial conductions are both 
present, the latter being, of course, the better. If 
bone conduction is the better, the defect is in the 
middle or outer ear. If bone conduction is lessened 
or lost, the trouble is in the nerve or its endings. 
When the semi-circular canals or the fibres from 
them are irritated, false sensations are received from 
them by the cerebellum and cerebrum ; the patient 
feels as if turning around, or as if falling in one di- 
rection or another. Such vertigo is known as aural 
vertigo if symptoms of auditory character are at the 
same time present. 

Meniere's Disease, 

so called, is an extreme form of aural vertigo, 
and is characterized by sudden attacks of violent 
vertigo, so violent at times that the patient feels 
it as a blow behind the ear, and may be 



21/ 

thrown to the ground. At the same time there is a 
loud and often shrill noise in one ear. The sufferer 
becomes pale, the face covered with sweat, and at 
the end of the attack, which may last in the begin- 
ning but a few minutes, there is vomiting or nausea. 
Consciousness is not lost, but in some cases mental 
confusion, with darkness before the eyes, is present. 

The symptoms are due to an affection of the 
labyrinth, such as haemorrhage (injury), inflammation, 
syphilis, etc. The manifestation of the trouble in at- 
tacks is difficult to understand as part of a pro- 
gressive disease, and they have been ascribed to 
variation of intra-labyrinthine pressure, due to changes 
of vaso-motor influence. 

In most of the cases deafness in some degree 
and tinnitus had been present, but occasionally deaf- 
ness did not appear for some hours or some days after 
the first attack. 

The attacks tend to increase in frequency, and 
finally the patient may be confined to bed, since 
the vertigo becomes continuous on movement. When 
the deafness becomes absolute the vertigo ceases as 
a rule, because the labyrinthine nerve organs have 
then been destroyed. 

That the symptoms can come from affection of the 
eighth nerve trunk or its so-called roots, is proven 
by F. Alt's report of a case in which the symptoms 
came on, and after the attack hearing was nearly 
lost. Total deafness existed two weeks later, not- 
withstanding which the patient kept to his bed on 



2 1 8 THE CRANIAL NERVES. 

account of the recurring vertigo. He was found to 
be suffering from leucocythsemia, and died in three 
months. 

The autopsy supported the diagnosis of leucocy- 
thsemia. Microscopic examination showed the middle 
ear to be intact, the labyrinth without evident 
change, but the inner and outer nerve roots showed 
spots of small-celled lucsemic infiltration and the 
trunk of the nerve slight degeneration. Here then 
was a case with well-marked Meniere's symptoms 
in which the labyrinth was not involved. In another 
way the case is worthy of note, and, perhaps, 
makes a point of diagnostic import between affec- 
tion of the labyrinth and that of the nerve — deaf- 
ness, even when total, was not accompanied by ces- 
sation of the vertigo. 

Diagnosis. In severe cases of Meniere's syndrome, 
epilepsy may be erroneously diagnosticated. The 
sudden fall, the partial (even momentarily complete) 
loss of consciousness would make us suspect the pres- 
ence of the latter disorder, but deafness is in favor 
of the former. Dr. v. Frankl-Hochwart maintains 
that cases of epilepsy occur in which the attack 
is ushered in with vertigo, tinnitus, nausea and vomit- 
ing, but without loss of hearing. Cases of epi- 
lepsy with Meniere's triad as the aura, cannot be 
differentiated from the genuine Meniere's disease if 
demonstrable ear affection is present. 

Treatment of any form of aural vertigo must be 
largely influenced by discoverable cause, such as 



219 

middle ear disease, affection of the Eustachian tube, 
syphilis, etc. Symptomatically, Natrum salicylicum and 
Chininum sulphuricum are both well indicated and have 
repeatedly benefited. A typical case, which had been 
in the hands of several aural specialists, was relieved 
entirely and rapidly by the writer's prescribing CJieno- 
podium antJielminticum cum Terebintliina (in 3d dilu- 
tion), the mixture having been that taken by the 
involuntary prover. The deafness was intense, the 
patient only hearing conversation if it was very loud, 
yet she could distinguish the tinkle of the door bell 
two stories below ; this symptom is found in Allen's 
Encyclopedia, Vol. X., under Chenppodium. 

Other remedies reported as serviceable are Aurum 
metallicumj Ledum palustre, Tabacum and TJwridion, 

The glossopharyngeal or ninth cranial nerve is a 
mixed nerve. Its sensory fibres arise from the cells 
of the petrosal ganglion in the foramen jugulare and 
pass outward to subserve with common sensation and 
the special sense of taste the posterior third of the 
tongue and with common sensation the root of the tongue, 
pharynx, soft palate, Eustachian tube, tympanum and 
upper part of larynx. 

The centripetal fibres from the same cells pass in- 
ward and enter the medulla in the postero-lateral 
groove and reach the sensory nucleus where they end. 
The second neurone arises from the sensory nucleus 
and ends near the cells of the temporal lobe. 

The motor fibres arise from the nucleus ambiguus, 
dorsal to the olivary body. They pass out in the 



220 THE CRANIAL NERVES. 

same groove with the sensory fibres and form a com- 
mon trunk. They are finally distributed to the muscles 
of the palate, pharynx and the middle constrictor of 
the oesophagus. 

Isolated disease of the ninth cranial nerve has not 
been observed, owing to the difficulty of detecting it. 
Irritation of its fibres would produce the globus sen- 
sation as seen in hysteria, but this is to be considered 
as cortical in origin. Paralysis of the nerve would 
cause loss of taste and tactile sensation in the posterior 
third of one-half of the tongue and loss of tactile sen- 
sibility in other parts named above. Its nucleus is 
affected in bulbar paralysis (q. v.). 

The tenth cranial or vagus nerve is a mixed 
nerve having both motor and sensory fibres. The 
latter arise from cells of the ganglion jugulare (Henle), 
otherwise called the ganglion of the root (Quain, 
Gray) within the jugular foramen. They are dis- 
tributed to the dura mater of the occipital region 
and posterior fossa, to part of the external auditory 
meatus, to the oesophagus, pharynx and stomach, to 
the larynx and whole respiratory tract. 

The centrally directed fibres from the ganglion 
pass into the medulla below the glossopharyngeus 
and reach the sensory vagus nucleus below the 
floor of the fourth ventricle, practically continuous 
with that of the glossopharyngeus in front. 

The motor fibres of vagus arise from the motor 
nucleus, the nucleus ambiguus (common to the ninth 
and tenth cranial nerves). The fibres pass out by 



THE CRAXIAL XERVES. 221 

several rootlets, having been joined by some fibres 
from the nucleus of the spinal accessory nerve just 
back of the vagus nucleus, and are sent to the mus- 
cular structures of the pharynx, larynx, oesophagus, 
stomach and intestines, as well as to the trachea and 
bronchi. 

The vagus contains both accelerating and inhibit- 
ory fibres for the respiratory centre, for the heart, 
and for the vaso-motor centre. 

Secretory fibres are sent to the abdominal viscera 
and to the respiratory tract. 

The wide distribution of the vagus fibres, the 
many functions which they subserve, especially in 
the thoracic and abdominal viscera, make affections 
of this nerve, for the most part, subjects for the 
consideration of the general practitioner. 

Affections of the nerve will be described in con- 
nection with the eleventh nerve. 

The spinal accessory or eleventh cranial neive 
arises in part from the posterior portion of the motor 
vagus nucleus in the medulla, from which, indeed, 
as has been stated, fibres join the root of the vagus 
while yet within the medulla. Some fibres from the 
nucleus join the vagus after emergence. 

Another portion of the nerve, the spiual portion, 
arises from the cells of the lateral and of the outer 
part of the anterior gray horn of the cord, their lowest 
origin being about the level of the fifth cervical nerve. 
The fibres pass outward through the lateral columns 
by several roots and ascend, successive additions being 



222 THE CRANIAL NERVES. 

made at each higher level. The trunk thus formed 
passes into the cranium through the foramen magnum 
and then turns outward to emerge from the cranium 
by the jugular foramen. Within the skull the fibres 
of spinal origin are joined by those arising from the 
nucleus in the medulla, but upon the emergence of 
the common trunk the latter divides into two branches, 
an inner and an outer. The former joins the vagus, 
contains the fibres from the nucleus in the medulla, 
and innervates the muscles of phonation ; the latter 
contains the fibres of spinal origin and innervates the 
sterno-mastoid muscle and the upper part of the trap- 
ezius. 

Paralysis of the vagus includes the fibres of the 
spinal accessory from the medulla. In such paralysis 
the palate hangs down on the side affected, it is not 
raised in intoning, the speech becomes nasal and in 
swallowing liquids a part may escape by the nose. 
The pharyngeal muscles being affected, swallowing is 
difficult. The laryngeal muscles show paresis of the 
abductor of the vocal cord of the affected side, and 
if paralysis, the cord is in the cadaveric position and 
immobile. The heart's action may be accelerated, but 
this is usual only when the nerves of both sides are 
affected; the breathing then becomes slow and irreg- 
ular. 

Defective contraction of the stomach with faulty 
digestion and loss of the sensation of hunger can 
result from a paralyzing lesion of the nerve; irritat- 
ing lesion has caused insatiable appetite. 



THE CRANIAL NERVES. 223 

Lesions of the nerve may be from affections of the 
base of the skull or of the upper vertebrae, from 
meningitis, syphilis, etc. Lesion of a division of the 
nerve can occur from injury, pressure of a tumor or 
by direct poisoning, as in diphtheria. 

Spasm in the distribution of the vago-accessorius 
nerve may affect the pharynx and oesophagus (globus) 
or the larynx (laryngismus stridulus, larynx "crises" 
in locomotor ataxia). 

Treatment of affections of the nerve must be purely 
symptomatic unless the cause can be traced (meningitis, 
syphilis, etc.). Reference to the section on Bulbar 
Paralysis may give some hints. 

A lesion of the spinal or accessory portion of the 
eleventh cranial nerve causes paralysis of the sterno- 
cleido and trapezius muscles. In consequence the 
head cannot be turned to the opposite side, nor the 
shoulder of the affected side raised. The full contour 
of neck and shoulder region is changed and appears 
sunken. 

Only the upper portion of the trapezius is com- 
pletely paralyzed, the other portions being also in- 
nervated by the cervical nerves. The scapula is more 
distant from the spinal column than normal and is 
also rotated, the lower angle being nearer the spine 
than normal. Atrophy is present. 

If both nerves are affected both sets of muscles 
that support the head are affected, and there will be 
inability to hold the head up, so that the latter falls 



224 THE CRANIAL NERVES. 

forwards or backwards in accordance with the pull 
of gravity. 

Lesion of the nerve within the skull or in the for- 
amen magnum may he by pressure from exudation, 
meningitis, etc. Below the foramen, disease of the upper 
vertebrae and injury, etc., can affect it. In progressive 
muscular atrophy its nuclear origin may become in- 
volved. 

Spasm in the distribution of the spinal part of the 
spinal accessory nerve will be considered in the section 
on Spasmodic Diseases. 

Treatment of paralysis of this part of the nerve 
must be first for any underlying cause or any in- 
cluding disease (bulbar paralysis, progressive muscular 
atrophy). 

The hypoglossal or twelfth cranial nerve arises 
from the cells of a nucleus beginning in the lower 
portion of the medulla and placed antero -laterally to 
the central canal. Towards the rest of the brain the 
canal is gradually displaced dorsally until it merges 
into the widening posterior fissure and opens out as 
the fourth ventricle. The nucleus of the twelfth nerve 
is placed obliquely, so that it gets nearer to the canal 
and the opening of the fourth ventricle and its upper 
part is below the floor of the latter and near the 
median line. 

From the long nucleus fibres arise which pass down- 
ward and outward between the pyramid and the olive 
to emerge as the twelfth nerve roots. 



THE CRANIAL NERVES. 



225 



The nerve supplies the muscles of the tongue, both 
intrinsic and extrinsic and the genio-hyoid muscle. 

Paralysis of the nerve after its emergence from the 
medulla may be by compression from exudation, tumor; 
in the foramen and lower down by similar conditions 
or by disease of the bone. 

Within the medulla it may be affected (and usually 
bilaterally) in bulbar paralysis. 

In paralysis of one hypoglossal nerve the affected 
side of the tongue lies higher at the base than does 
the other half; when protruded it deviates curved 
towards the paralyzed side. When moved within the 
mouth its back part deviates towards the unaffected 
side. 

If both nerves are affected the tongue lies motion- 
less on the floor of the mouth; speech and eating are 
greatly interfered with. For further description and 
treatment vide section on Bulbar Paralysis. 

Fig. 27. The positions 
of the different nuclei of 
origin of the cranial nerves 
will be understood by study 
of the accompanying fig- 
ure, which represents the ] 
structures between the an- 
terior pair of the corpora 
quadrigemina and the up- 
per portion of the spinal 
cord. The structures of 
the right half are seen. 
To the left and below Bad. 
anter.= anterior nerve 
root. XI and bracket are 
at the nucleus of the elev- 
enth nerve ; fibres pass 
dorsally and are seen at 
the side as rootlets. Near 
them is a line, finely dot- 
ted, the common ascending 
root of the eleventh and 
tenth nerves. They pass under the end of the upper dark mass, which is the nucleus of the tenth 
nerve posteriorly and of the ninth anteriorly. Above this conjoint nucleus is seen the nucleus 
of the twelfth. In the middle of the picture, extending lengthwise, is seen a thick dotted mass 
traceable into the pons, where it turns down and out. It is the so-called ascending root of the fifth 
nerve. Fs.=sensory root of fifth nerve ; Fm. =motor root, whose fibres can be seen coming from its 
nucleus, the dark egg-shaped mass above. From the sensory root of the fifth a thick line can be 
traced upward into the region beneath the corpora quadrigemina ; it is the descending root of the 
fifth. The long dark mass in the middle beneath the nucleus of the ninth and tenth is the large 
nucleus of the eighth nerve ; its fibres are entering at VIII, passing under the other nucleus of the 
eighth nerve. Just above the latter nucleus is seen a scattered nucleus, that of the seventh nerve, 
whose fibres gather together and course over and around the sixth nerve nucleus. The roots of 
these two nerves are sufficiently well indicated. IV, near corp. quad., shows both fourth nerves 
crossing. At III are seen fibres of the third nerve coming from its nucleus. 




fi ons Var<^ 



Fig. 27. 



The Brain. 

The Brain- Axis. By the term brain-axis is meant 
the brain structures between the lower end of the 
medulla and the optic thalami. It therefore embraces 
the medulla, pons Varolii, crura and the corpora 
quadrigemina with their included structures. 

As many special nervous masses and fibre-tracts 
are mentioned in the present section and have been 
alluded to in the preceding one it is deemed advisable 
to consider here briefly the finer anatomy of the brain- 
axis and chiefly by the description of illustrations. 

At the level of the first cervical nerve a section 
of the spinal cord shows some variation from the usual 
appearance of a lower section. 




* 

Fig. 28. 
Fig. 28. From Henle. Fg, Fuuiculus gracilis or column of Goll ; 
Fc, funiculus cuneatus or column of Burdach ; Cgp, posterior cornu ; 
Cga, anterior cornu. 



THE BRAIX-AXIS. 



227 



The ascending posterior columns have increased 
greatly, the posterior gray horns are thrust outward 
and have become smaller and at the end of each is 
seen, turned anteriorly, the large mass of gelatinous 
substance of Rolando. 

A section in the lower pail of the medulla shows 
the ending of the decussation of the pyramids, the fibres 
of which are seen crossing the middle to get into 
the lateral column of the opposite side. The anterior 




Fig. 29. 



Pig. 29. From Henle. Decussation of the pyramids. Kg, nucleus 
of Goll's column ; (/, gelatinous substance at head of posterior gray 
horn. 



gray horns are thus separated from the central gray 
matter. A spinal rootlet of the eleventh cranial nerve 



228 



THE BRAIN. 



is seen emerging at the left. In the column of Goll 
the nucleus of that column is beginning. 

Figure 30 shows a section of the medulla a little 
higher. The decussation of the pyramids is just be- 
ginning, a few fibres of each crossing. The nucleus 
of the column of Goll fills nearly all the area formerly 




Fig. 30. 

Fig. 30. From Henle. Decussation of the pyramids at the level of the lower 
roots of 12th cranial nerve. Nc, nucleus cuneatus or nucleus of column of 
Burdach. Figs. 28, 29 and 30 show the gray matter in light tint, the white 
matter in dark. 



occupied by fibres and the nucleus cuneatus or nucleus 
of the column of Burdach is quite large. 



THE BRAIX-AXIS. 



229 




Fig. 31. 

Fig. 31. From Obersteiner. The structures shown in the right half are 
explained diagramatically in the left half. iVrt, motor nucleus of ninth and 
tenth nerves. IX a, ascending root of ninth nerve. Sgl, substantia gelatin- 
osa. VOL, descending spinal root of fifth. Crst, the restiform body. IlS, 
direct cerebellar tract. Oi, inferior olive. Lm, lemniscus. Py, pyramid. 



Figure 31 represents a section of the medulla 
through the calamus scriptorius. The opening above 
is the beginning of the fourth ventricle. The pyra- 
mids are intact. The olivary body, the tenth and 
eleventh nerves coming from their nuclei, the restiform 
body and the direct cerebellar tract are to be noted; 
fibres (at x) coming from the nuclei of the posterior 
columns are seen to curve to the middle line and 
cross. The twelfth nerves frame as it were between 
them the interolivary tract or lemniscus. 



230 



THE BRAIN. 




Fig. 32. 

Fig. 32. From Obersteiner. Cbllm, part of cerebellum. VITI, the eighth cranial nerve. Villi, 
lateral root. Vlllm, median root. VIII ac, accessory nucleus. VIII Jl, chief nucleus of the 
eighth. JV VII, nucleus of the seventh. VII a, root fibres ascending from the same. 



Figure 32 shows a section of the medulla made at 
the striae acusticae. The floor of the fourth ventricle 
is wide and flat, the covering cerebellum has been 
cut away except at the sides of the section. 

The restiform body is seen surrounded by the roots 
of the eighth cranial nerve emerging as one trunk 
below. The seventh nerve nucleus is seen giving off 
fibres which here pass upwards. 



THE BRAIN-AXIS. 



231 




Fig. 33. 

Fig. 33. From Obersteiner (reduced). N VI, nucleus of sixth cranial nerve 
giving off fibres which descend (shown as thick lines). VII b, ascending 
fibres of seventh cut across. VIIc, descending fibres of seventh. Xdt, nucleus 
dentatus of the cerebellum. Flp, posterior longitudinal fasciculus. 



Figure 33 shows a section of the pons. The con- 
nections with the cerebellum have been cut away. 
The motor tract fibres are not in a compact mass as 
in the pyramid of the medulla, but are in bundles 
separated by the cross-fibres of the pons. A portion 
of the seventh nerve nucleus is seen at this level 
giving off some fibres which ascend. The fibres from 
the lower level have already ascended to turn around 
and over the sixth nerve nucleus, but the turn or 
knee is at a level a little higher and camiot be seen 
in this section, but as they turn backward they are 
again seen in the section, and pass downward. 
The restiform body has at this level become really 
the inferior peduncle of the cerebellum. The lem- 
niscus is in a compact mass and in the field above 
is the formatio reticularis. 



232 



THE BRAIN. 




Fig. 34. 

Fig. 34. From Obersteiner (reduced). Lng, Lingula ; Vlma, velum 
medullare anticum. Brcj, superior peduncle of the cerebellum. Vd,'de- 
scending root of fifth cranial nerve. Flp, posterior longitudinal bundle. 
Lm, median lemniscus. Lml, lateral lemniscus. Frtg, formatio reticu- 
laris. Py, pyramidal tract separated into bundles by the cross fibres of the 
pons. 



Figure 34 shows a section beyond cerebellar struc- 
tures. The superior peduncle of the cerebellum is 
seen coming from its place of origin (?), to be shown in 
the next figure. The lemniscus has separated into 
two distinct bundles of fibres — the lateral or lower 
lemniscus, which goes to the region of the corpora 
quadrigemina, and the median or upper lemniscus, 
which terminates in the cortex of the parietal lobe. 
The formatio reticularis and the posterior longitudinal 
bundle are indicated. 



THE BRAIN- AXIS. 



233 




Fig. 35. 

Fig. 35- From Obersteiner (greatly reduced). Tho, optic thalamus. Cgm, 
internal geniculate body. C'/l, external geniculate body. II, optic tract. 
_Pp, pes or crusta of the crus cerebri. SnS, substantia nigra. Ntg, red nucleus 
of the tegmentum. 777, fibres of the third cranial nerve. N III, nucleus of 
the third nerve. Lm, median lemniscus. Aq, aqueduct of Sylvius. 



Figure 35 shows a section through the anterior 
pair of the corpora quadrigemina, the crura cerebri, 
through part of the optic thalami and of the external 
geniculate bodies. Around the aqueduct is seen the 
central gray at whose outer limit is the descending 
root of the 5th cranial nerve ; below the aqueduct and 
lateral from it is the nucleus of origin of the 3d 
cranial nerve, from which the nerve fibres are going 
downward to emerge through the crus. They pass 
the posterior longitudinal bundle just beneath the 
central gray and through and around the red nucleus 
of the tegmentum. The lateral lemniscus has dis- 
appeared, the median one remains. The large mass 
of substantia nigra separates the pes or foot of the 
crus from the parts above, all the latter being in- 
cluded under the word tegmentum. 



234 



THE BEAIN. 




Fig. 36. From Bechterew. 
A schematic representation of 
the course of fibres from the 
nuclei of the posterior columns 
of the spinal cord to and 
through both lemnisci and to 
the cerebellum. 

C, the cortex ; nl, the lenti- 
cular nucleus ; th, the optic 
thalamus ; cL, Luys' body or 
corpus subthalamicum ; qa and 
qs, the corpora quadrigemina ; 
nil, nucleus in the lateral lem- 
niscus ; OS, the superior olive ; 
VIII, anterior acoustic nerve 
nucleus ; oi, the olivary body ; 
nla, nucleus of antero-lateral 
column ; nip, nucleus of pos- 
tero-lateral column ; nfc, nu- 
cleus cuneatus, at the top of 
the column of Burdach ; nfg, 
nucleus gracilis or nucleus of 
the column of Goll ; cr, resti- 
form body becoming the inferior 
peduncle of the cerebellum. 
The fibres in the latter can be 
traced in the figure and need 
no explanation, except to say 
that fibre 2 represents the di- 
rect cerebellar column of the 
spinal cord. 

The course of fibres from the 
nucleus of the lateral columns 
is not given They get into the 
formatio reticularis 1 vide Figs. 
31 and 34) and ultimately reach 
the parietal cortex. 



Recent investigations by A. Hoche, of Strasburg, 
give new light on the course of the column of Growers 
or antero-lateral tract. 

His results support the conclusions of H. T. Patrick, 



THE BRAIN-AXIS. 



235 



of Chicago, and others, who traced the fibres of this 
column in lower animals to the region of the corpora 
quadrigemina, where they turn backward with the 
superior peduncle of the cerebellum and end in its 
middle lobe. Hoche's investigations were on man, 
with the same result. Edinger had already proposed 
that the antero-lateral tract and the direct cerebellar 
tract be termed cerebello-spinal tracts, ventral and 
dorsal, respectively. Gowers' column, in view of these 
new facts, cannot now be considered as carrying pain- 
and temperature-sense impulses. 




Fig. 37. 
From Edinger. 



236 



THE BRAIN. 



Figure 37 gives a side view of the brain axis with 
the optic thalamus and part of the cerebral cortex. 
Fibres going to the occipital lobe from the primary 
optic centre are marked "stabkranz" (corona radi- 
ata). The left optic tract has been cut across, so that 
the chiasm with the remaining portions of the optic 
nerves is hanging to the right, out of its proper place. 
The word " fuss" is upon the foot or pes of the right 
eras cerebri. The geniculate bodies are indicated, the 
external or lateral one and the internal or median one 
being so designated. Of the corpora quadrigemina the 
positions of the two on the right side are shown and 
designated. The arm or brachium from each is seen. 
The three peduncles of the cerebellum are seen cut 
across, and their relative positions shown. The word 
"bindearm" is upon the superior, the word "pons" 
is on the middle, and the term corpus restiforme is 
upon the inferior peduncle. 




Fig. 38. 
From Edingei. 



PROGRESSIVE BULBAR PARALYSIS. 237 

Figure 38 gives a view of the inferior surface of 
the brain-axis with the left hemisphere of the cere- 
bellum attached. At the optic tract in front, the 
chiasm and attached portions of the optic nerves have 
been turned backward. Pes pedunculi=pes or foot 
of the crus cerebri. The places of exit of the cranial 
nerves are marked by a Roman numeral in each case. 

Progressive Bulbar Paralysis. — Glosso-labio-phar- 
yngeal Paralysis. The disease is a progresssive de- 
generation affecting the motor nuclei existing beneath 
the floor of the fourth ventricle. Its cause is un- 
known ; its relation to degeneration of the motor cells 
in the anterior gray horns of the cord has already 
been stated. It is seen mostly in the latter half of 
adult life, the majority of the cases occurring between 
the ages of 50 and 60. It has been ascribed to ex- 
posure to cold, to trauma, to over-use of the related 
muscles, to lead poisoning, syphilis, great emotional 
strain, and one case appeared after an attack of diph- 
theria. 

Its onset is very gradual, the first symptoms being 
those of the tongue, whose finer movements in articu- 
late speech become impaired, the sounds represented 
by the letters 1, t, d, n and r being the first to become 
indistinct in enunciation. Later, the letters k, g hard 
and j are imperfectly uttered. The tongue may by 
this time show some gross changes ; it cannot be freely 
or fully moved and may show some area of distinct 
atrophy. Later the lips become affected and the 
labials p, b, f, v, m, as well as the vowel o, cannot 



238 THE BRAIN. 

be properly sounded. When the muscles of the soft 
palate become involved, a nasal tone is given to the 
speech, and from imperfect closure of the posterior 
nares in attempting to swallow liquids, the latter may 
come out of the nose. 

The oesophageal muscles being affected, swallowing 
becomes a matter of difficulty, and, as there is im- 
perfect closure of the larynx, there is danger of 
invasion of the larynx and bronchi by foreign matters 
and the consequent setting up of pneumonia. When 
the laryngeal muscles are well involved the voice is 
weak or veiled or even absent, while coughing is 
impossible or toneless. 

The atrophy of the tongue increases so that its 
movement is eventually impossible, and as it lies at 
the bottom of the buccal cavity it usually exhibits a 
peculiar fibrillary tremor to be likened to a fine 
vermicular motion ; furrows and depressions in the 
tongue show the atrophy. The lips also become 
atrophic, are incapable of closure, so that the mouth 
is always more or less open, and the patient cannot 
blow or whistle or smile. From the open mouth (the 
lower lip and chin hanging), the saliva drools con- 
stantly, while the muscles of the upper part of the 
face being unopposed, the naso-labial folds are more 
pronounced than normally and the face takes on an 
expression of pain. Sensation is not affected, except 
that a feeling of tension is felt in the muscles of the 
throat, but the pharyngeal reflex becomes lost. 

The electrical reactions may show no change from 



ACUTE BULBAR PARALYSIS. 239 

the normal until the disease has well advanced, and 
then only the partial reaction of degeneration. 

The disease is slowly progressive, yet most of the 
cases end fatally within three years or so ; cases have 
been reported in which the lethal termination occurred 
within the first year. 

The fact that the degeneration is only part of a 
widespread process in the motor nuclei, whether of 
the anterior gray horns below or of the region of 
the aqueduct of Sylvius above, must be held in mind 
in considering the prognosis. The disease is incurable. 

An acute, apoplectic form of bulbar paralysis, due 
chiefly to thrombosis or embolism, occasionally to 
haemorrhage, exists. With this, since other parts in 
addition to the motor nerve nuclei of the bulbar region 
are involved, there are usually some additional symp- 
toms as well as the suddenness or rapidity of onset, 
to serve as guides in diagnosis. Paralyses in the limbs, 
rapid pulse, disturbances of respiration and at times 
implication of the bladder, put the trouble outside the 
category of degenerative nuclear disease. Tumors 
affecting pons or medulla may by pressure give rise 
to many of the symptoms of bulbar paralysis, but the 
existence of syphilis, of cardiac affection, or of vas- 
cular disease, will direct the attention aright. 

Pseudo-bulbar paralysis must be borne in mind as 
a possibility. It is due to symmetrically placed lesions 
in the cortex of both cerebral hemispheres or in the 
basal ganglia on both sides. The symmetry in location 
on the two sides will not be absolute and the apoplectic 



24O THE BRAIN. 

onset, or the occurrence of stages of advance, will 
distinguish this form from the slowly progressing 
trouble due to degenerative disease in pons and me- 
dulla. 

A special form of disease having bulbar paralytic 
(and sometimes atrophic) symptoms, mostly with some 
ophthalmoplegia, and in many of the reported cases 
muscular asthenia which may involve all the limbs, 
has been described by a number of observers. The 
disease may begin with ptosis (one-sided or bilateral) 
or some other muscular affection of the eye. Here> 
as also in all the muscles involved, the special feature 
is myasthenia, so that a few efforts tire out any muscle 
for the time being, and this exhaustibility appears 
under tests by the faradic current, the muscle respond- 
ing fairly well at first, the response failing after a 
few contractions have been elicited. The condition 
worsens, but after a time, it may be months, improve- 
ment may set in and an apparent restoration occur. 
This recovery is believed to be deceptive and to mean 
only remission. Cases have died after return of the 
disorder following a complete apparent recovery lasting 
several years. 

Post-mortem examination has so far revealed nothing 
to account for the symptoms. 

The bulbar affection just described has lately at- 
tracted a great deal of attention. Oppenheim has 
termed it bulbar paralysis without post-mortem find- 
ings; Jolly, amyosthenia gravis pseudoparalytica ; and 
Strlimpell, asthenic bulbar paralysis. As Erb had re- 



PSEUDO- BULBAR PARALYSIS. 24 1 

ported three cases of the affection in 1878, it has 
been called Erb's disease, but the name asthenic bulbar 
paralysis is generally accepted. 

The treatment of bulbar paralysis must be largely 
guided by the diagnosis in any case. In the pseudo- 
bulbar paralysis (from cortical lesions) remedies must 
be addressed to such lesions if possible, and greater 
weight must be given to the non-bulbar symptoms. 

In the apoplectic form, while the bulbar symp- 
toms must be guides in choosing a remedy, never- 
theless the character of the lesion, when this can be 
ascertained even as a probability, may make a change 
in the selection. 

The true degenerative form will require the reme- 
dies that are known to produce similar degeneration. 
Dr. Berridge, of London, reported as a fact that 
workers in binoxide of manganese are frequently af- 
fected by bulbar paralysis. The writer has used this 
drug in one case without result, but in a case of the 
apoplectic variety, the symptoms having existed with- 
out material change for two years, the Manganum 
binoxide given three or four times a day in third tri- 
turation caused marked improvement in speech, power 
of swallowing, and other symptoms. 

Lilienthal in his therapeutics (made up of clinical 
reports of cure or improvement) gives Plumbum, 
Caasticum, Cadmium sidph., Phosphorus and Nux 
vomica as having been serviceable in bulbar pa- 
ralysis, but without differentiating between types of 
the disease. 



242 THE BRAIN. 

Two cases of the asthenic form are at present un- 
der the writer's care. Manganese binoxide 3d trit. 
was given in both cases without any perceptible ef- 
fect. Nux vomica 2x seemed to hold the disease in 
check, but one patient said it stimulated him, yet had 
no effect on his speech or power of swallowing. 
Hydrophobinum 200 (given because of the nerve cen- 
tres affected) brought great relief, and then because 
of the choking in a dangerous degree that came on 
when laughing, Stannum 200 was prescribed, and with 
marked improvement. Meanwhile, the speech has be- 
come better, its tone less nasal, but some myasthenia 
is present, so that he has to take a period of rest 
before any business interview. It is typical of such 
cases that their symptoms are always better in the 
morning after a good rest, which brings Phosphorus 
to mind as a remedy. 

Prof. Jolly in reporting his cases, mentions the fact 
that the symptom myasthenia as seen in them was 
very like that produced by proto-veratrine. In a case 
of bulbar affection not of the asthenic variety, but 
due to syphilis and probably gummatous, seen by 
the writer several times in consultation, the physician 
had prescribed Veratrum viride, low, on the indica- 
tions characteristic of that drug, especially those of 
the tongue. Whenever he withdrew the remedy, the 
bulbar and paralytic symptoms distinctly worsened. 
The patient was supported for many weeks by rectal 
feeding, and received large doses of Potassium iodide 
in the same way, but notwithstanding the use of the lat- 



DISEASES OF THE CENTRAL XERVOUS SYSTEM. 243 

ter drug, it is more than doubtful that his recovery 
from the dangerous bulbar symptoms, which resulted 
after a few months, would have occurred without the 
special influence of the Veratrum. 

Diseases of the Central Nervous System. 

Under the term central nervous system are in- 
cluded all nerve structures existing from the cerebral 
cortex down to, but not including, the ganglion cells in the 
anterior gray horns of the spinal cord and the places 
of entrance into the posterior part of the spinal cord 
by the posterior spinal nerve roots. The word brain 
means all the nerve structures within the skull cavity, 
and these are divisible into five pairs of organs, three 
of which are evident on inspection of the brain when 
removed from the skull ; the remaining two, being 
buried within the brain mass, are recognizable after 
section as anatomical entities only by a knowledge 
of development. 

The brain developes from five fundamental brain 
vesicles (originally three primary ones) in such way 
that the first (beginning at the nasal end) grows at 
such a rapid rate that it covers in all the others ; 
the second and third develop to a less extent, re- 
taining their original relatively central position, while 
the fourth developes laterally into two large masses; the 
fifth undergoes but little enlargement. The structures 
of the fourth and fifth, although covered in from 
above, are readily seen from below. 

The first is the cerebral hemisphere; the second 



244 THE BRAIN. 

the thalamus ; the third the corpora quadrigemina 
anterior and posterior of one side, the fourth is pons 
and cerebellar hemisphere, while the fifth is a lateral 
half of the medulla, In each case there is a pair 
separated or nearly separated, one from the other, 
except in the third and fifth where the separation is 
only indicated by a more or less distinct raphe. 

The functions of the brain structures are the ag- 
gregations of the functions of their individual neu- 
rones, and these functions are of two kinds — that 
is to say, the cell body either sends out or receives 
impulses. A centrifugal impulse or one from the cortex 
to the periphery, is a motor impulse; a centripetal 
one or one from the periphery to the cortex as the 
final or end station, is a sensory impulse. 

Motor impulses are of one kind only — that is, they 
cause contraction of muscle fibre. Hence, it may be 
assumed that if a motor impulse from cells in a cor- 
tical area in relation to, say, the right leg, could be 
switched off, as it were, so as to reach a muscle of 
the left forearm, that muscle would be put into ac- 
tion. It is otherwise with sensory impulses. Here 
the end-organs are highly differentiated, so that quali- 
ties of heat, cold, simple touch, pain, the degree of 
flexion of a limb, or the amount of contraction of a 
muscle, can be in each case correctly appreciated. 
It is to be assumed that could the cells of the 
organ of Corti replace the rods and cones of the 
retina, the former would not be affected by the rays 
of light falling on the pigment layer — they were not 



DISEASES OF THE CENTRAL NERVOUS SYSTEM. 245 

diner entiated for such purpose. On the other hand, 
it may be that the end-organs of the skin are not 
so highly differentiated as has been just suggested, 
but that they receive different impressions and send 
inward impulses of a general character, which, in 
turn, are taken up by intercalated neurones acting 
as transformers, and passed on as fully differentiated 
qualities of sensation. In this way may be explained the 
existence of a chain of several neurones which exist 
in the pathway of sensory conduction; for the con- 
duction of centrifugal motor impulses but two neurones 
are needed, both being long ones, the central neurone 
beginning as the cell of the motor area of the cortex 
and ending in the neighborhood of the large gang- 
lion cell of the anterior gray horn of the cord, which 
cell is the beginning of the peripheral neurone, 
whose terminus is in the end plate upon a muscle 
fibre at the periphery. 

The neural pathways between the cortex and 
periphery, both sensory and motor, form the projection 
system of fibres. 

The optic thalamus is the fully developed second 
fundamental brain vesicle. It is in connection ap- 
parently with all parts of the cerebral cortex of its 
own hemisphere and sends also fibres downward, some 
of which join those of the motor tract whose cells 
act independently of volition. The thalamus is divisible 
into five large irregular and unequal masses, the 
larger posterior one being the pulvinar. 

The third fundamental brain vesicle in developing 



246 THE BRAIN. 

gives rise to the corpora quadrigemina and the struc- 
tures below them, including the nuclei of origin of 
the third and fourth cranial nerves. The vesicle 
develops inwardly instead of outwardly, so that in- 
stead of large ventricular spaces there is a channel of 
small lumen known as the aqueduct of Sylvius, and 
which is all that remains there of the original 
neural tube. Below are the crura cerebri, not sepa- 
rable anatomically from tissue above ; yet as they 
are composed largely of the motor and sensory tracts, 
together with other fibre tracts, they cannot be considered 
genetically as derived from the vesicle in question. 

The fourth vesicle develops laterally into two 
masses, the cerebellar hemispheres, from each of 
which fibres pass inwards, decussate in the middle 
line, and go forward to the frontal lobe of the oppo- 
site cerebral hemisphere. 

The mass of fibres on each side and at the cross- 
ing, form a considerable part of the bulk of the pons 
Varolii, which also holds the motor and sensory tracts 
in their passage downward and upward, respectively. 
Still further increasing the bulk of the pons, are the 
nuclei of the fifth and sixth cranial nerves. 

The fifth brain vesicle develops into the medulla 
oblongata, which contains anteriorly the motor tracts 
now united into compact masses of fibres, known as 
the pyramids of the medulla, the continuation upwards 
of sensory pathways, the nuclei of cranial nerves from 
the seventh to the twelfth, and specialized structures 
known as the olivary bodies. 



THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 



247 



The Cerebral Cortex and the Cortical Areas. The 
cerebral cortex is composed so largely of cells that 
on section it appears gray. It is in folds or con- 
volutions (also termed gyri); the depths or de- 
pressions between them are termed fissures (or 
sulci). The fissures appearing earlier in fcetal life 
are known as primary fissures and are an inch or 
more in depth. These are the fissure (so-called) of 
Sylvius, the fissure of Rolando, the interparietal — all 
on the outer face of the cerebral hemisphere, and on 
its inner face the parieto-occipital and the calcarine 
fissures. Between the cerebral hemispheres at the 
top is the great longitudinal fissure completely separat- 
ing the two hemispheres in the frontal and occipital 
regions, but in the middle only as far below as the 
corpus callosum. 




Fig. 39. 
From Edinger. 



248 



THE BRAIN. 




Fig. 40. 
From Edmger. 

Figures 39 and 40 show the locations and names 
of the different convolutions, lobes and fissures. The 
frontal lobe extends as far backward as the fissure 
of Rolando and downward to the fissure of Sylvius. 
It extends over and around to the inner face of the 
hemisphere as far back as the calloso-marginal fissure 
and an indeterminate line ascending from the latter 
to the upper edge of the hemisphere. 

The parietal lobe is included between the fissure 
of Rolando in front, the fissure of Sylvius below and 
a line drawn from the posterior end of the latter to 
the lower end of the anterior occipital fissure, thence 
extending to the parieto-occipital notch. On the inner 
face of the hemisphere the parietal lobe is represented 
in the precuneus between the ascending part of the 
calloso-marginal and the parieto-occipital fissures. 



THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 249 

The boundaries of trie occipital lobe are the parieto- 
occipital notch above, in front the interparietal and 
anterior occipital fissures and a line from the anterior 
end of the lateral occipital fissure downward to the 
lower edge of the hemisphere. On the inner face 
of the latter the occipital cortex is in the cuneus and 
the lingual lobule. 

The temporal lobe includes all of the cortex below 
the fissure of Sylvius and in front of the imaginary 
lines already described in bounding the parietal and 
occipital lobes. Beneath, it is continuous with the 
occipitotemporal convolution, and on the inner face, 
with the uncinate gyrus and the gyrus of the hippo- 
campus. 




Fig. 41. 

Fig. 41, from Edinger, shows the convolutions on the under surface of the 
cerebral hemispheres. The convolutions or gyri are marked on one hemisphere, 
the fissures or sulci on the other. Their continuance with the inner and outer 
face of the hemispheres is readily seen. 



25O THE BRAIN. 

The cells of the cerebral cortex are of different 
kinds and have been depicted as being in several 
layers, from four to nine in number according to the 
views and interpretation of the observer. The cells 
may be classified according to their respective functions 
and these are to send out to or to receive impulses 
from the periphery (here meaning any part outside 
the brain) and to interact among themselves in co- 
ordinating or integrating separate impulses or in arous- 
ing to activity cells not directly impressed (reproduc- 
tion of memories, association of ideas). 

The neuraxones from the cells of the motor area 
and the fibres bringing sensory impulses to the sensory 
areas are called the projection system of fibres; fibres 
passing from the cells of one convolution to those of 
another in the same hemisphere make up the as- 
sociation system of fibres ; and fibres that connect the 
cells of any cortical part of one hemisphere with the 
analogous part of the other are known as the com- 
missural system of fibres. 

A motor impulse (projection system) is 
carried by two neurones only, a central and a 
peripheral one. The sensory path to the cortex from 
the periphery is over two or more neurones. In the 
association system there are long tracts as well as 
very short ones ; thus, the frontal lobe is connected 
with the temporal and occipital lobes, the extremes 
of the temporal and occipital lobes are connected by 
fibre tracts that can be readily demonstrated. 

The fibres of the commissural system make up the 



THE CEREBRAL CORTEX AXD THE CORTICAL AREAS. 25 I 

bulk of the corpus callosum and the anterior white 
commissure. 

Experimental investigation on the lower animals 
and accidental ones on man have shown conclusively 
that certain definite areas of the cerebral cortex sub- 
serve certain functions ; that when a certain part is 
excised or otherwise destroyed there follows loss ot 
motor power in a definite part of the body and that 
if in another animal the same cortical area be irritated 
there appears motion (spasm) in the part analogous 
to that paralyzed in the previous experiment. Further, 
the proof from pathology puts the truth of the doctrine 
of brain localization beyond question. 

To go more deeply into the methods of these in- 
vestigations or their history is beyond the scope of 
this book. Their results as at present accepted are 
shown in Figure 42. 

The cortex of the central convolutions of one hemis- 
phere is the motor area for the opposite half of the 
body and is divisible into three sub-areas, the upper 
third for the lower limb, the middle third for the up- 
per limb and the lower third for the face (including 
lips, tongue, larynx, and pharynx). 

Finer subdivisions of these sub-areas has been fig- 
ured by different authors but have not as yet received 
full acceptance. 

The sensory impulses from the periphery are re- 
ceived by the cells in the posterior central convolution 
and probably also in the cortex extending a little be- 
hind the interparietal fissure. It is held by many that 



252 



THE BRAIN. 



there are cells with sensory function in the anterior 
central convolution. 

The cortical areas for some of the special senses 
are well known. The visual cortical area is in the 
occipital lobe and chiefly in the cuneus with some 
extension to the occipital convolutions on the outer 
face of the hemisphere. 

The auditory area occupies the greater part of the 
superior and middle temporal convolutions. 

The areas for taste and smell are in the convolution 
of the hippocampus and in the uncinate gyrus (some 
writers give just the reverse). 




Fig. 42. 

Fig. 42. From Edinger (modified). The motor speech area is indicated by the word Sermo ; the 
auditory speech area by the word Auditus ; the visual language area by ViSUS lit., and the visual 
perception memory area by V. percep. 

In the figure the tip of the temporal lobe is assigned by Edinger as the cortical area for the sense 
of taste. In the text an alternative location is given. 

It is axiomatic now that when a cortical cell acts 
for the first time it undergoes some change, that 
some permanent alteration is thereby made in it and 
that when it is called upon to act again the individual 



THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 253 

is conscious that he has had such experience before. 
This is the explanation of memory. If the first im- 
pression or change in the cell were made under special 
intensity, or if the action be sufficiently often repeated 
the individual can at will call up a mental image of 
the object seen, or a mental reproduction of the sound 
heard (in the case of such sensory impressions) or can 
repeat some intricate muscular action. We possess, 
therefore, the faculty of memory not only for sensation 
received but for motor impulses sent out. 

The child learns to talk by a very slow continuous 
process lasting during several years. And when it 
has learned, its faculty of articulate speech is simply 
the aggregate of all its motor memories of how to 
arrange its lips, tongue and pharyngeal muscles to 
produce certain definite sounds. The area for such 
muscular memories is located in the posterior part of 
the inferior or third frontal convolution. This is also 
called Broca's centre, from the name of the physician 
who first successfully called attention to disease of 
this area as the cause of loss of the speech faculty 
without loss of power in the muscles used in speech 
production. 

This result is termed motor aphasia ; the subject 
not only cannot speak, but he also cannot repeat what 
another has requested him to say, nor can he read 
aloud. 

The areas for sensory memories of language are in- 
cluded in or are near to the sensory areas for hearing 
and sight. 



2 54 TH E BRAIN. 

The area for auditory speech memories embraces 
the posterior half of the first temporal convolution and 
a small part of the second. Destructive lesion of this 
area causes loss of the memories of the meanings 
that the individual has learned to attach to certain 
uttered sounds or words. Hence, a person so affected 
is, when hearing his own language spoken, as one 
listening to a foreign tongue. He is not deaf, for 
sounds other than those of language are heard and 
appreciated as well as ever. The condition is known 
as auditory or sensory aphasia. In this case he can 
speak but is apt to use words wrongly; he cannot 
speak " after" another, nor read aloud correctly, be- 
cause he no longer has the regulating influence of 
the auditory speech centre. 

Visual memories related to language are those of 
printed or written words. They are stored up in the 
cortex of the angular gyrus. Destructive lesion in this 
area causes loss of the ability to read and the individual 
is in the position of one who has never learned to read. 
The condition is known as word blindness or alexia. 

An infrequent form termed optical aphasia is that 
in which the individual while recognizing by sight 
certain objects (watch, stove, etc.,) and knowing their 
purpose yet cannot "find" their names, but may be 
able to do so when aided by the sense of touch or 
of hearing, from whose speech centres the motor speech 
memory may be aroused. The lesion is believed to 
be in the cortex between the angular gyrus and the 
extremity of the auditory speech area. 



THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 255 

The areas for language are marked in Fig. 42, page 252. 

Writing from a copy or at dictation may be either 
lost or retained in motor aphasia ; in auditory aphasia 
the former is retained, the latter lost. As the lesion 
may not be destructive of a whole area, degrees of 
loss in the different aphasias must exist and in many 
cases affected, a complicated symptomatology is pres- 
ented. As the different speech centres are connected, 
each with all the others, by association fibres, it is 
evident that a lesion interfering with conduction along 
one or more of these pathways must cause disturbance 
in the inter-relation of those centres among themselves. 
Finally, lesion in the path way s of conduction of the motor 
speech centre with the organs of speech, and of the 
organ of hearing with the auditory speech centre, causes 
aphasia of a simpler type than in the cortical forms. 
The making of a schema explanatory of the physio- 
logical bases for the production of speech and its 
understanding, brings into the problem elements that 
are psychological, which must in any case be influenced 
and varied by the inventor's self-introspection. 

Paraphasia is the faulty use of words by substitu- 
tion ; the individual intending to ask for water, for 
instance, may utter the word " stable " or some other 
unrelated word. Conversation becomes almost impos- 
sible when paraphasia exists. It is evidence of loss 
of conduction between the speech centres or of a 
lesion in the auditory area; it does not occur in sub- 
cortical sensory aphasia, and, of course, will not exist 
in cortical complete motor aphasia. 



256 THE BRAIN. 

The terms just used are, cortical, meaning that the 
actual cortical area is directly affected; sub-cortical, 
when the pathway between the peripheral organs and 
the related areas is injured. The term transcortical, as 
applied to aphasia, means that the pathway from a 
supposititious "idea" centre (which in turn is used 
only to represent concretely the summation of all the 
memories such as the color, shape, weight, tempera- 
ature, smoothness or roughness, taste, odor, etc., which, 
taken together, make up the idea of an object), to the 
motor speech area or from the sensory speech areas to 
the assumed "idea" centre, is injured. 

A "writing centre" in the cortex is not believed to 
exist. 

Voluntary writing is initiated in the young, and in 
the poorly educated adult, primarily from the arbitrarily 
assumed "idea" centre via the motor speech centre. 
Thus may be explained the movements of lips and 
tongue in children when learning to write and also in 
the adult who rarely writes. In the ordinarily well 
educated person the writing act is probably dominated 
by the auditory memories of the words to be written, 
hence from the auditory speech centre ; in those whose 
intellectual work is predominantly reading, the act of 
writing is probably immediately governed from the 
visual centre for language. 

The schema, Fig. 43, of Wernicke, and the explan- 
atory table, apply to pure cases of isolated forms. 
Such cases are not common, and when two or more 
forms are associated the results of examination of the 



THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 257 



patient's powers of language may not be susceptible 
of satisfactory interpretation. 



a 




a \ — Ifi 



Fig. 43. 
Cortical a. — Loss of understanding uttered language 
Cannot speak after another 
" write at dictation 
" write voluntarily 
" read aloud 
Can copy 

Can speak voluntarily but with paraphasia 
Cortical b. — Cannot speak voluntarily 

" speak after another 
" write from dictation 
" write voluntarily 
" read aloud 
Can understand what is spoken 
Can copy 
Subcortical a. — Cannot understand uttered language 
" speak after another 
" write from dictation 
Can write voluntarily 
" copy 

" speak voluntarily 
" read both to one's self and aloud 
Conduction aphasia, between a-b. — 

Can speak voluntarily and after another 
" understand spoken words 
" copy 
Cannot read aloud 

" write at dictation 
" write voluntarily 
Transcortical b. — Cannot speak voluntarily 
" write voluntarily 
Can speak after another 
" understand spoken language 
" read understandingly and aloud. 
" copy 

" write from dictation 
Subcortical b. — Cannot speak voluntarily 

" speak after another 
Can copy 
" understand spoken language 
" read understandingly 
" write at dictation 
" write spontaneously 
" express number of syllables in a word 
Transcortical a-.B — 

Cannot understand words heard 

" understand what he reads 
Can speak after another but without understanding 
read aloud without understanding 
write voluntarily but with paragraphia 
write at dictation 

speak voluntarily but with paraphasia 
copy 



258 THE BRAIN. 

a represents the auditory cortical speech area; &, 
the motor cortical speech area. B, the assumed 
idea centre. The dark lines below a and b are the 
pathways from the auditory organ, and that to the 
organs of speech respectively. The arrow - heads 
show the direction of conduction. 

The association fibres between the auditory speech 
area and the motor speech area are represented by 
the line from a to b. Interruption in it causes con- 
duction aphasia. 

Destructive lesion at a causes cortical auditory aphasia. 

Lesion at b causes cortical motor aphasia. 

Lesion in the fibres (dark line) below a causes 
subcortical auditory aphasia. 

Lesion in the fibres (dark line) below b causes 
subcortical motor aphasia. 

Lesion between a and B causes transcortical au- 
ditory aphasia. 

Lesion between b and B causes transcortical motor 
aphasia. 

Alpha represents the cortical visual language area; 
beta represents the motor area for right hand. In 
reading aloud the visual area arouses the auditory 
area a, and this, in turn, the motor speech area b. 
Understanding what is read is by continued trans- 
mission from alpha to a and thence to B. 

Writing at dictation is via a, alpha, beta. 

Copying needs only the visual language area and 
the motor area in left hemisphere for the hand, and 
association fibres, thus alpha — beta. 



THE CEREBRAL CORTEX AXD THE CORTICAL AREAS. 259 

The visual memories of objects perceived are 
stored up in the cells of the angular gyrus, but as 
it is next to the supramarginal gyrus, disease of one 
area often affects the other. Hence, with loss of 
the power of reading there is frequent association of 
loss of the recognition of familiar objects. The latter 
condition is known as apraxia; in it the patient is 
unable to recognize by sight objects of every-day 
life, but may be able to do so through uuinjured 
areas for other modes of recognition. Thus, a watch 
being unrecognized by sight may be at once cor- 
rectly perceived when it is placed near the ear and 
its ticking heard. 

Lesion of the fibres beneath the angular gyrus has 
been oftener noted than lesion in the cortex. 

The various sensory and motor faculties connected 
with language are in the left cerebral hemisphere in 
right-handed persons; in left-handed persons they are 
in the right hemisphere. In either case after de- 
struction of an area the corresponding area of the 
opposite hemisphere soon learns to act as substitute. 

The visual memories of objects (perception) ap- 
pear to be represented in the angular gyri of both 
hemispheres. (See Fig. 42, page 252.) 

Aphasia must be distinguished from dysarthria or 
anarthria, in which the muscular activities involved 
in producing articulate speech are impaired or lost 
as a result, commonly, of degenerative disease in the 
medulla (vide bulbar paralysis). 

Aphasia is only a symptom, most frequently from 



260 THE BRAIN. 

lesion in the affected area, or the many association 
paths from one area to another. It occurs also as a 
result of toxic influences (infectious diseases, uraemia, 
etc.), from trauma (depressed fracture of the skull af- 
fecting one or more of the areas related). It also 
may appear in conditions of exhaustion and after 
fright ; in the latter case if complete motor aphasia 
exist it may be difficult to distinguish it from hys- 
terical muteness. 

Treatment. When an organic affection is the cause 
of aphasia the treatment must be directed to such 
disease. When functional only, the symptom aphasia 
will be taken into account. 

Our materia medica contains very little of purely 
aphasic symptoms of any one variety. Motor aphasia 
is found under Chenopodium antJielminticum ; para- 
phasic symptoms are given under Natrum mur., Cal- 
carea carb., and Lycopodium ; alexia, under Lycopo- 
dium, Hyoscyamus and Plumbum, and optical aphasia 
under Baryta acetica. Some of the symptoms given 
are possibly due to general mental weakness and the 
differentiation of remedies for the varieties of aphasia 
must be made now from clinical experience. 



THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 26 1 




Fig. 44, from Edinger, shows a 
perpendicular transverse section 
of the brain through the optic 
thalami. The left optic thalamus 
is shown separated from the right 
one by the third ventricle. The 
positions of the nucleus caudatus 
and nucleus lentiformis and the 
relation of the three bodies to the 
internal capsule are evident. To 
the outer side of the lenticular 
nucleus is seen the cortex of the 
island of Reil at the bottom of 
the so-called fissure of Sylvius. 
The positions of the corpus cal- 
losum, fornix and optic nerves, 
all cut through, are indicated. 
The drawing is largely schematic. 



Fig. M. 



Fig. 45, from Edinger, 
is a horizontal section of 
the brain. The various 
parts are indicated by 
their names. Balken = 
corpus callosum. 




Fig. 45. 



262 THE BRAIN. 

Anaemia of the Brain. 

As an independent primary condition anaemia of the 
brain cannot exist, but is found as a secondary state, 
the result of vascular disease or of cardiac weakness, 
or as part of a general anaemia. 

In its acute and usually temporary manifestation 
the symptoms may be alarming to lay observers. 
This is termed syncope or a fainting fit, and is com- 
monly caused by fright or similar emotional shock, 
which by influencing the heart results in lessening 
or stopping the flow of blood to the brain. The 
symptoms are mental confusion, loss of vision, vertigo, 
nausea, loss of power over the limbs, so that the pa- 
tient falls and then remains apparently unconscious, 
or nearly so, for a short time, varying from a minute 
or a few minutes to a considerable fraction of an 
hour. In less severe cases the above-mentioned 
symptoms are less in degree. 

In cases of chronic cerebral anaemia there are 
drowsiness, which is replaced by insomnia on lying 
down (effect of position), mental depression, apathy, 
with inability or aversion to work, attacks of fainting, 
weakness of memory, etc. All of the symptoms ex- 
cept insomnia are relieved by lying down. 

The prognosis of the acute condition, especially 
as seen in young persons, is favorable, and there is 
no danger to life even in a prolonged syncope when 
it is not dependent upon an excessive loss of blood 
or pronounced cardiac disease. 



HYPEREMIA OF THE BKAIN. 263 

In chronic cerebral anaemia tlie prognosis is that 
of the underlying cause. 

Treatment of an attack of syncope should always 
include placing the patient in a horizontal position 
without pillow for the head, and stimulating reflexly 
the respiratory and cardiac centres by dashing cold 
water on the face and chest. 

Hyperemia of the Brain. 

When, from any cause, the flow of blood into the 
cranial cavity is in such amount or at such rate that 
the veins cannot carry it off in equal degree there 
is present an excess of arterial blood; and when 
the capacity of the veins is for any reason increased 
in relation to a normal influx of arterial blood, 
there will be an excess of venous blood. Both con- 
ditions are hyperaemias, the former being termed 
active, the latter passive. Active or arterial hyper- 
aemia may be produced by strong emotion, such as 
a fit of anger, by the action of certain drugs, such 
as alcohol, nitrite of amyl, nitroglycerine, etc., by a 
cold bath, etc. Passive or venous hyperaemia is usually 
a continuous state dependent upon some mechanical 
obstruction to the venous efflux from the brain, 
such as tumors of the neck pressing upon the jug- 
ular veins, certain diseases of the heart, emphysema 
of the lungs, etc., but a passing hyperaemia of this 
kind follows muscular effort in which the diaphragm 
assists, as in the case of lifting heavy weights, strain- 
ing at stool, etc. 



264 THE BRAIN. 

Repetition of the causes of arterial hyperemia re- 
sults in a more permanent dilatation of the arterioles 
and this in turn gives rise to retardation of the blood 
current with consequent lessened rate of metabolism 
within the brain, an engorgement hypereemia, yet with 
many of the symptoms seen in states of cerebral 
anaemia. 

The symptoms of acute arterial hyperemia of the 
brain are a rising of heat to the head and face, with 
a sense of distension, pulsation felt in the carotids 
and head, headache, at times vertigo or even partial 
obscuration of consciousness. The symptoms are 
aggravated by stooping, coughing, lying down, etc. 
Such acute congestion may be accompanied by a rise 
of body temperature, and cannot be distinguished 
from the early stage of a meningitis. Passive hyper- 
emia from venous obstruction below has similar symp- 
toms, but usually of less intensity and without the 
marked pulsation seen in the active arterial type. In 
continued or chronic states of engorgement hyper- 
emia due to loss of tonicity of the vessels' walls, 
there are sleeplessness with more or less drowsiness 
when up and about, weakness of the mental powers, 
especially when concentration of mind is required, 
headache, with emotional depression or even unmotived 
anxiety or morbid fears. This condition is cerebral 
neurasthenia. 

Prognosis in cases of active or arterial congestion is 
good, except where cardiac disease seems to be the 
cause ; in the form due to venous obstruction the 



CEREBRAL MENINGITIS. 265 

prognosis is that of the causal condition ; in the form 
due to vascular dilatation the prognosis for cure will 
depend on the length of time the condition has existed, 
upon the underlying cause (alcohol, tobacco, etc.). In 
cases of recent origin or where reformation in the 
mode of life can be established, a cure may reasonably 
be expected. Oppenheim considers that masturbation 
plays a predominant role in causing dilatation of the 
cerebral blood vessels. 

The treatment of cerebral hyperemia must be by 
remedies chosen with recognition of the causal con- 
dition if such can be found, and the accompanying 
symptoms. As a symptom, a congestive cerebral state 
can be produced by very many drugs; in the Symptom 
Register to Allen's Encyclopedia 52 drugs are given 
under the rubric Congestion of the Head. The rem- 
edies most often indicated in the condition are Bella- 
donna, Hyoscyamus, Melilotus, Opium, Lachesis, Calcarea 
carbonica, Ferrum phosphoricum, Nux vomica and Vera- 
trum viride. JDirca palustris and Fagopyriim esculentum 
have been eifective in the writer's hands. In pas- 
sive hyperemia Chloral hydrate 30, Baryta carbonica, 
China, Silicea, Piper methysticiim and Amyl nitrite in 
potency have been of great value. In any case the 
accompanying symptoms should decide the choice of 
the remedy. 

Cerebral Meningitis. 

Inflammations of the meninges of the brain are classi- 
fied as pachymeningitis and leptomeningitis according 



266 THE BRAIN. 

to the membrane chiefly affected, the dura, or the pia 
and arachnoid. 

External pachymeningitis (dura mater) occurs at 
times as a result of disease in the skull bones. Its 
symptoms are the general ones, fever, headache, per- 
haps delirium or even convulsions and its relief or 
cure depends on removal or lessening of the externally 
acting cause. 

Internal pachymeningitis is haemorrhagic in its 
nature, the haemorrhage occurring in successive out- 
breaks. The effused blood becomes organized and 
forms layers of connective tissue which are readily 
separable on post-mortem examination and are studded, 
especially the innermost ones, with minute new haemor- 
rhages. 

The thickening thus formed acts as an extra-cerebral 
tumor and upon its location will depend the special 
symptoms. It occurs in chronic alcoholism, in dementia 
paralytica or other chronic wasting disease of the 
cerebral cortex, as well as in chronic kidney disease. 
It is stated to have been observed in individuals of 
the hemorrhagic diathesis and during the course of 
pernicious anaemia, leucaemia, scurvy, etc. 

Light cases may show only the symptoms of some 
general affection of the brain, but in a severe case 
there is marked cerebral excitation similar to that of 
delirium tremens, or a unilateral epileptiform attack. 
This may be followed by a comatose state that may 
last for days or even weeks (Oppenheim). With the 
usual signs of increased brain pressure the first attack 



LEPTOMENINGITIS. 267 

may end fatally and then cannot be distinguished from 
an apoplexy, but if recovery occurs it is apt to be 
complete. The diagnosis is difficult and at first may 
be impossible ; the chief point is the recurrence of 
symptoms of cortical irritation in an alcohol habitue , 
an old person, or alter external injury to the head. 

Leptomeningitis or inflammation of the pia (and 
usually the arachnoid) occurs in three or four distinct 
forms — the purulent, tubercular, syphilitic, and an 
epidemic form known as cerebro-spinal meningitis. 

Purulent leptomeningitis is caused by some pyogenic 
micro-organism; thus the disease is an outgrowth of 
some infectious process in a part of the organism other 
than the brain. Thus pyaemia, septicaemia, pneumonia, 
scarlet fever, and similar diseases may give rise to 
an infection of the meninges via the blood vessels. 
Direct invasion, by way of the sheaths, along the out- 
side of nerve trunks, or of vessels from suppurating 
neighboring structures is not uncommon. Injuries to 
the head resulting in an open wound may give access 
even through unbroken bone to the germs (v. Berg- 
mann). 

The disease-process affects chiefly the convexity of 
the cerebral hemispheres, but in many cases the mem- 
branes at the base are also involved. Hyperaemia of 
the pia-arachnoid, then thickening and turbidity and 
next the appearance of pus, mostly aggregated along 
the fissures, is the order of succession. The cortex 
may become involved, small haemorrhages, foci of sup- 
puration and an interstitial oedema being present ; or 



268 THE BKAIN. 

the ventricles may show inflammation of their lining, 
often with a sero-purulent fluid within or even a real 
hydrocephalus. 

Fever in the beginning and of atypical course, with 
or without a chill, violent headache, continuous but 
with times of aggravation, obscured consciousness with 
delirium or sopor are common symptoms, while during 
the delirium and even in sopor, evidences of the ex- 
istence of severe headache are present. The pulse 
is often irregular, bowels confined, abdominal walls 
retracted and extreme hyperesthesia both of the 
periphery and of the special senses is present. Con- 
vulsions may occur, either general or limited to one 
side or to a single limb. 

When the disease-process affects the basal mem- 
branes the symptoms are those of compression or 
irritation of the cranial nerves, such as paralyses or 
spasm of ocular muscles, inequality of pupils, absence 
of the light-reflex, optic neuritis, facial paralysis or 
facial spasm, gnashing of the teeth or even trismus. 

Perhaps the most diagnostic symptom of meningitis 
of any kind that has invaded the posterior fossa of the 
skull is the retraction of the head, with rigidity of the 
neck, often accompanied with rigidity of the limbs. In 
the later stages coma with loss of the deep reflexes comes 
on, together with irregular and rapid pulse, rapid and 
sometimes irregular respiration or respiration of the 
Cheyne-Stokes variety. Death occurs in the increas- 
ing coma or in convulsions. 

The disease is always acute in character and may 



TUBERCULAR MENINGITIS. 269 

end fatally in a few days, but more commonly it lasts 
from one to two weeks. When coma comes, a fatal 
ending may be predicted (Oppenheim). 

Recovery lias been observed, in one case of the 
writer's with serious damage to the cranial nerves 
and the mental powers. 

The prognosis is always grave. 

The diagnosis will be made from the rapid oc- 
currence of cerebral symptoms in individuals suffering 
from septic or suppurative processes in other parts, 
or from infectious diseases. But these diseases them- 
selves may begin with cerebral symptoms that later 
clear up. 

Tubercular meningitis, like purulent meningitis, is 
to be considered a secondary disease, but, unlike the 
latter, is always due to the invasion by the same 
bacillus or to the effects of its toxine. Its victims are 
never those in good health, although in some instances 
it may appear to be the primary disorder, but are 
pale, weak, ill-nourished, " scrofulous" individuals, 
already affected with some form of tuberculous de- 
posit. 

It is mostly seen in children between the ages of 
two and twelve, but occasionally in the adult. 

The disease is characterized by a long prodromal 
stage, as might be inferred from the kind of bacillus 
at work. The tubercle bacilli being carried via the 
blood vessels to the meninges, settle thereon and, as 
a result of their presence and irritative action, inflam- 
matory exudative changes in the membrane occur, 



27O THE BRAIN. 

with subsequent changes known as the eruption of 
miliary tubercles, in which the characteristic bacillus 
tuberculosis is found. The process is mostly at the 
base, but usually extends to the spinal membranes. 
Along the fissure of Sylvius and other large fissures 
on the convexity, tubercles and exudation are found, 
but in less amount. 

The prodromal symptoms are those of general mal- 
aise. The child becomes languid, refuses to play, 
becomes irritable or moody, with restless nights or 
even sleeplessness. Headache comes on, at first light 
and temporary, later severe and continuous, yet with 
periods of violent exacerbation, and vomiting without 
cause and projectile in character, constipation and 
occasional rises of temperature. Intermittency of these 
symptoms is to be expected during its early or pro- 
dromal stage, which may last during three or four 
weeks or may extend over a much longer period. 

When the disease has, so to say, settled, and the 
meningitic process has begun, the headache becomes 
continuous and intense, delirium appears, with great 
restlessness, fever of an irregular type, pulse showing 
the same peculiarity, but more often slow, partial 
or general convulsions, gnashing of the teeth ; the 
sleep, such as it is, is interrupted by a sudden pierc- 
ing scream (cri hydrencephalique), 

The symptoms due to irritation or pressure at the 
base are those of interference with the cranial nerves 
there, especially the ocular nerves. Inequality of the 
pupils with dilatation (less often contraction), with 



CHRONIC MENINGITIS. 2J\ 

loss of the light-reflex, paralytic strabismus, associated 
deviation of both eyes to one side and even optic 
neuritis are symptoms to be looked for. Symptoms 
due to implication of structures in the posterior fossa 
are retraction of the head, with rigidity of muscles 
at the back of the neck, with extension to the back, 
and even the limbs. 

The delirium passes into sopor and then into coma, 
deceptive remissions being not infrequent ; the coma 
becomes more profound, the respiration irregular, as- 
suming at times the Cheyne-Stokes type, a general 
paralytic state of the muscles replaces rigidity, and 
with a rapid rise at times (104° or 105° F.), or 
lowering of temperature (96° F., or even lower) 
death ensues. 

The lateral ventricles generally contain an increase 
of fluid, turbid or at times sanguinolent in character; 
this state of hydrocephalus interims may be ex- 
tensive enough to affect, by pressure, the cortex. 

Diagnosis is to be made chiefly by the history 
(tuberculosis elsewhere), the age of the patient, and 
the early cerebral symptoms coming on in spells 
either singly or grouped. 

Prognosis is bad, but cases have been reported in 
which cure has resulted ; here the question of diag- 
nosis must be brought forward. 

Chronic meningitis as a manifestation of chronic 
alcoholism appears predominantly on the convexity, 
while when the result of the syphilitic process it 
affects chiefly the base. The symptoms in either case 



272 THE BRAIN. 

are those of meningitis of the related type, although 
of less intensity, but the diagnosis of chronic menin- 
gitis, except when the above-named etiological con- 
ditions can be shown to exist, is practically impossible 
during life. Cases are said to have occurred as the 
sequel or continuation of the acute cerebro- spinal 
meningitis or of insolation. 

Epidemic cerebro-spinal meningitis is a disease 
due to a germ similar to if not identical with the 
pneumococcus. The disease occurs in the temperate 
zones, especially during the winter and spring, and 
in crowded dwellings, and chiefly among children and 
youthful individuals. It appears epidemically, but its 
distribution seems to depend in some degree upon 
climatic or ether similar conditions, since it is a rather 
common affection in some parts of the United States, 
while it is rare in other parts in nearly the same 
latitude. Sporadic cases, of course, can occur. 

The invasion by the disease is rapid and in some 
cases almost sudden. The early symptoms are general 
malaise, chilliness, restlessness, pains in the back and 
back of head and at times in the extremities, and 
the evidences of a ssvere illness are apparent. Next, 
vomiting, hypersensitiveness to noise, light and touch, 
with delirium and fever, come on. The temperature 
is variable, rarely goes beyond 104° F.; the pulse is 
rapid and also variable. Of diagnostic value is the 
appearance of herpes labialis in the early days of the 
disease. Retraction of the head, stiffness of the neck 
muscles, and contraction of the muscles of the back, 



EPIDEMIC CEREBROSPINAL MENINGITIS. 273 

even to the production of opisthotonos, are symptoms 
that come on within the first few days, in varying 
degree. In most cases, some form of eruption appears 
on the skin, such as erythema, urticaria, roseola, 
purpura, the latter being of great diagnostic value. 
General convulsions may occur early in the disease 
and may recur. 

In unfavorable cases symptoms of paralysis with 
coma in the course of a few days or by the end 
of a week, and paralytic phenomena involving some 
of the cranial as well as the spinal nerves, are to be 
expected; these are myosis or other alteration of 
pupils, paralysis of muscles of the eyeballs, nys- 
tagmus, optic neuritis, partial or complete deafness, 
monoplegia, hemiplegia, or even paraplegia. 

In severe cases the disease runs a very rapid 
course, death occurring within a few days ; in cases 
of moderate severity the disease may extend over 
two or three weeks. The mortality varies in dif- 
ferent epidemics, in some 75 per cent, having been 
noted, the average being 57 per cent. (Oppenheim) ; 
towards the end of an epidemic lighter cases are in 
the majority. 

Pathologically the disease process is an inflamma- 
tion with fibro-purulent exudation in the pia extend- 
ing over the convexity and base of the brain, and 
also to the membranes of the cord with special ac- 
tivity around the lumbar enlargement. The cranial 
nerves, especially the optic, third and eighth are infil- 
trated or embedded, and the latter nerve may be a 



274 THE BKAIN. 

pathway for extension of the inflammation to the in- 
ner ear and middle ear. 

Diagnosis is not difficult in an ordinarily well 
marked case if similar ones exist in the immediate 
neighborhood (epidemic), but in sporadic cases the 
affection has to be differentiated from other forms 
of meningitis (tubercular) and from other infectious 
diseases, especially pneumonia, which, indeed, may 
be associated. An absolute diagnosis may be made 
by aspiration of the spinal canal in the lumbar 
region, the aspirated fluid showing the presence of 
the meningococcus intercellularis, or of the pneumo- 
coccus, the latter apparently being the more virulent. 
Herpes labialis does not occur in tubercular menin- 
gitis. 

Sequelae are blindness, deafness, chronic headache, 
chronic spinal meningitis, muscular incoordination, 
and sometimes paralysis. Blindness and deafness im- 
prove spontaneously in some cases, but in most re- 
main. 

The treatment of any form of cerebral meningitis 
must at first be largely symptomatic. IF any causal 
indication exist it should be heeded ; hence, in cases 
of traumatic origin Arnica will naturally be first 
thought of; if from exposure to excessive heat, 
Glonoine. In general, the symptoms in the beginning 
will call for Belladonna, Bryonia, Gelsemium or Aconite. 
Later, if symptoms of cerebral irritation are pro- 
nounced, Cantharis, Hyoscyamus, Cicuta virosa, Cimi- 
cifuga, Veratrum vir. or Zincum may be required. 



CHRONIC HYDROCEPHALUS. 



~/D 



If effusion is evident from the signs of increas- 
ing brain pressure, Apis, Hetteborus, Opium or Digi- 
talis may be required. Bryonia is highly regarded 
by different observers when there is excessive pain. 
Iodoform 6x or higher, has, in the writer's hands, 
been of signal service in chronic meningitis. Cuprum 
aceticum, Zincum met., Crotalus horridus, Rhus fox., 
Calcarea curb., Lycopodium and Sulphur have been 
reported as curative or beneficial. In all cases the 
symptoms should be the guide to the remedy. In 
tubercular meningitis the brain symptoms will not 
lead to a selection of a remedy for the real disease. 
The fatality of this form of meningitis will make it 
advisable to use TubercuVinum in a high dilution. 

Chronic hydrocephalus is, in the vast majority of 
the cases, a condition beginning in intra-nterine life. 
It may have advanced at term to snch degree as to 
cause difficulty in delivery or at such time it may 
be latent and only develop within a few weeks or 
months. 

The condition is an accumulation of fluid within 
the ventricles of the brain and is due to occlusion 
of the openings of communication between the general 
ventricular cavity and the cavity of the arachnoid, or 
between the cavities themselves. The development 
of the latent disorder may not occur until set in action 
by some accident, trauma, or some trifling intercurrent 
affection. 

The manifestation of the disorder is a gradually 
progressing enlargement of the head. The enlarge- 



276 THE BRAIN. 

ment is in all directions, forwards, backwards, later- 
ally and even upwards, but here the yielding of the 
fontanelles and opening of the partly closed sutures 
allows greater horizontal distension. The face, below 
the roofs of the orbits, of course, shows no change, 
and there is a marked contrast of small face and large 
head, the general outline being triangular when viewed 
from the front, while from above the outline is more 
or less round. Increasing pressure of the fluid within, 
results in a thinning of the skull bones, which in ad- 
vanced cases can be felt. 

Cerebral symptoms appear ; impeded development 
of the brain results in retardation of mental develop- 
ment as well as of muscular growth and control. The 
child cannot learn to walk, at times cannot sit up 
on account of the weight of the head, does not learn 
to talk. The cranial nerves are affected by the pres- 
sure, and strabismus and, occasionally, optic nerve 
atrophy are seen. 

The general state of the patient shows cerebral 
irritation ; the child is poorly nourished, generally 
wretched and unclean. Paresis of the lower limbs, 
with increased tendon reflexes, is not uncommon. 

The prognosis is bad, most of the cases dying 
within two or three years. Lighter cases may grow 
up, with development of mental and physical powers 
to a considerable degree, the enlargement of the 
head remaining. 

The diagnosis is to be made from rickets, or in 
later years from acquired hydrocephalus, the result 



ABSCESS OF THE BRAIN. 277 

of pressure by a tumor in the posterior fossa upon 
the vena magna Galeni, obstruction of the aqueduct 
of Sylvius, etc. In rickets the shape of the head is 
box-like, the fontanelles are not prominent, there are 
other evidences of the disease and cerebral symptoms 
are absent. 

The treatment of chronic hydrocephalus should be 
by the employment of our deeply acting remedies, 
such as Calcarea carb., Calcarea phos., Sihcea, Sulphur 
and Baryta carb. Rapid improvement must not be 
expected. In one case of the writer's after several 
months' treatment with some of the remedies just 
mentioned, marked change for the better appeared on 
giving Helleborus 6. 

Abscess of the Brain. The suppurative process in 
the brain requires the presence of a pyogenic mi- 
crobe. This may be introduced from without via a 
scalp wound (without any fracture of the underlying 
bone), or from within by direct invasion from some 
suppurating process in the neighborhood (chronic 
purulent otitis media), or by means of the blood ves- 
sels, from suppurative foci in distant parts (abscess 
of the lung, empyema, etc.). 

An acutely occurring abscess is chiefly seen as a 
result of trauma, and then affects the convexity, the 
symptoms being, like those of meningitis, mental con- 
fusion, delirium, fever of irregular type, with severe 
headache. If the motor area be involved, there will 
develop hemiplegia or monoplegia, preceded by epi- 
leptic convulsions. 



278 THE BRAIN. 

Acute symptoms may be the culmination of the 
chronic process. 

The other forms of brain abscess are of gradual de- 
velopment, and may remain latent for months or even 
years, the period of latency being characterized by 
irregular outbreaks of cerebral symptoms, with in- 
crease of temperature ; the acute episodical manifes- 
tation disappears, and the patient returns to a state 
of health, which, in turn, is again invaded by a re- 
currence of the previous symptoms. 

Headache, often of a severe type, is a frequent 
symptom; it is not seldom located at or over the 
site of the abscess. Vomiting is frequently seen; 
optic neuritis, while not uncommon, is yet less often 
observed than in brain tumor. The pulse is slow 
generally, but at times is accelerated. 

The cerebral hemispheres are much oftener the 
seat of abscess than the cerebellum, while abscess 
of the pons or medulla is rare. In the cerebrum 
the temporal and frontal lobes are more " often the 
seats of abscess, and if this is very extensive and deep, 
many of the underlying tracts will be invaded, giving 
rise to sensory aphasia (often misinterpreted as evi- 
dence of mental weakness — Oppenheim), injury to 
the motor tract, hemianopsia ; if in the occipital lobe, 
hemianopsia is to be expected. 

Brain abscess, if otitic in origin, will occur in 
either the temporal lobe or the cerebellar hemisphere, 
according to the location of the original affection on 
the anterior or posterior part of the petrous bone. 



ABSCESS OF THE BRAIN. 279 

Abscesses of distant origin (suppurative processes 
in the lungs, empyema, etc.) are located most often 
in the region supplied by the Sylvian artery; pyaemia 
frequently causes multiple brain abscesses. 

The diagnosis of abscess of the brain will rest 
upon the existence of some adequate cause, trauma, 
suppurative ear disease, etc., but tumor may occur 
after trauma. The recurrence of cerebral symptoms 
in attacks often ushered in by chills, the wide tem- 
perature range, the non-implication generally of the 
basal cranial nerves (except the optic, and occasion- 
ally the olfactory) are cardinal points. Acute abscess 
may end fatally before the specially diagnostic symp- 
toms appear, and then the diagnosis from acute 
meningitis may be impossible. Meningitis is not in- 
frequently set up by suppuration within the brain, 
while sinus phlebitis may occur from extension of 
the original ear affection. 

The course of acute abscess, or the terminal at- 
tack of the chronic affection varies. When trau- 
matic, the fatal termination is delayed more than 
when due to ear disease. In general, the time limit 
is from a few days to a very few weeks. Death 
occurs from coma and exhaustion, or from the 
breaking of the abscess into a lateral ventricle or 
externally, with consequent apoplectic or convulsive 
symptoms, with coma. 

The treatment of abscess of the brain is purely 
surgical. 



280 THE BRAIN, 



Apoplexy. 

Cerebral haemorrhage. A blood vessel ruptures 
under the pressure of the blood within it, either 
because of congenital or acquired weakness of its 
walls or from abnormal increase of the blood pres- 
sure, whether from kidney disease or cardiac hyper- 
trophy or both. 

The occurrence of intracerebral haemorrhage in 
the infant during the process of parturition may be 
considered as mechanical, owing to the prolonged 
or severe compression to which the yielding skull 
is exposed. Towards middle life the arteries mani- 
fest a degenerative change known as arterio-sclerosis, 
and this increases in degree with advancing years, 
being greater in some individuals than io others. 
Such degeneration is hastened by certain diseases, 
or by long-continued poisoning by certain substances 
(chronic kidney disease, the long-continued use of 
alcohol, etc.), while the haemorrhagic diathesis, leu- 
cocythaemia, pernicious anaemia and syphilitic disease 
of the blood-vessels within the skull cavity, are 
more direct causes of haemorrhage. 

The influence of heredity is seen in the occur- 
rence of cerebral haemorrhage during several suc- 
cessive generations, either through inherited weak- 
ness of the vessels themselves, or tendency to dis- 
eases causing the weakness. Miliary aneurisms 
situated on the circle of Willis or the arterial 



CEREBRAL HEMORRHAGE. 28 I 

branches arising therefrom, are frequently the sites 
at which haemorrhages occur. 

Given weak arteries with spots of advanced de- 
generation and aneurismal protrusions, any sudden 
increase of blood pressure, as in physical exertion, 
strong emotion, after a heavy meal, etc., may deter- 
mine a break in a blood vessel ; but, without this, the 
time must come when the vessel will finally yield 
under the ordinary blood pressure, and it may be, as 
is not infrequently the case during sleep. 

Prodromal symptoms are rather rare ; when present 
they consist of vertigo, pressure in the head, cardiac 
anxiety, paresthesia of one side, perhaps some mental 
confusion and difficulty of articulation, but such symp- 
toms are not necessarily prognostic of an oncoming 
haemorrhage. 

The attack comes on suddenly and in most cases 
during apparent good health, the patient falls to the 
ground and is at once comatose ; the face is turgid, 
red or purplish ; all the reflexes are gone, including 
the pupillary and corneal reflexes ; the pulse is full, 
strong, and may be slow or normal or accelerated in 
rate ; the skin is usually moist. 

The respirations are slow and stertorous and with 
each expiration the cheeks puff out. Urine and faeces 
may pass involuntarily ; the former generally contains 
some albumen. The limbs are entirely relaxed, yet 
when lifted and let drop a difference may often be 
observed, those of the paralyzed side drop like lead, 



282 THE BRAIN. 

those of the other side sink rather than drop, owing 
to some muscular tonicity remaining. 

The temperature may fall a degree or two during 
the first half day, then it ascends to the normal and 
may even rise beyond it, while the surface temper- 
ature on the paralyzed side is a degree or two higher 
than on the normal one. Subnormal temperature, if 
considerable in degree or long continued, is of evil 
omen. 

Should the case progress to a fatal termination, 
there will be generally a rapid rise of temperature, 
disturbance of respiration, which may take on the 
Cheyne-Stokes rhythm, rapid pulse ; if the end be 
delayed beyond a few hours, hypostatic engorgement 
of the lungs is apt to occur, death following within 
a day or two. In more prolonged cases the coma 
may lessen, the corneal and swallowing reflexes return, 
but the reactive inflammatory process around the 
effused blood introduces a fresh element of disturb- 
ance, delirium often coming on and lasting until death, 
or being replaced by sopor, coma or other symptoms 
with lethal ending. 

In favorable cases coma lessens within a few 
hours, a soporous condition serving as transition stage 
before even temporary consciousness returns, the 
deep reflexes appear gradually, movements of the 
unparalyzed limbs occur, as during restless sleep, 
and when the patient emerges into consciousness 
there is found some emotional or mental weakness. 

The most marked effect of cerebral haemorrhage 



CEREBRAL HAEMORRHAGE. 283 

is hemiplegia, face, arm and leg being affected, but 
the distribution of the facial nerve to the frontalis, 
corrugator supercilii and orbicularis palpebrarum muscles 
are usually not implicated, because the central neurones 
for them are not in the pyramid tract. The hypo- 
glossal distribution is involved in the paralysis, hence 
the unopposed action of the genio-glossus of the 
sound side causes deviation of the organ to the 
paralyzed side when the tongue is protruded. Im- 
plication of the lower face muscles is shown by 
asymmetry of the angles of the mouth, the cheek 
of the affected side being lower and that of the 
sound side being higher, owing to the unopposed 
tonicity of its muscles. 

Some degree of anaesthesia is noticed in many 
cases in the paralyzed parts, and the cremasteric 
and abdominal reflexes are absent on the paralyzed 
side. Within a short time the knee-jerk of the af- 
fected side becomes exaggerated. Later, ankle clonus 
can often be obtained. With right - sided paralysis 
some kind of aphasia, motor or auditory, is to be 
expected; it is often temporary. 

The symptoms following a stroke of apoplexy 
are classed as temporary, and permanent ; the former 
are also called indirect, because they are not from the 
direct destructive influence of the lesion which causes 
permanent effects, since a destroyed nerve fibre in 
the central nervous system cannot be replaced or 
restored. Many symptoms are thus indirect. Some 
amount of voluntary control reappears in the af- 



284 THE BRAIN. 

fected limbs ; the face loses most of its asymmetry ; 
the leg recovers its powers to a large degree ; the 
arm, while not so helpless as at first, improves in 
only a slight degree. 

Rigidity of the muscles of the affected limbs comes 
on in some cases early ; that is, within a day or two ; 
it may pass away soon or stay for a week or two. 
But between two and three weeks after the seizure 
there occurs the late rigidity with contractures. The 
latter are characteristic when fully developed, the 
fingers being flexed, the hand flexed on the arm, the 
forearm flexed and pronated, the arm adducted. The 
lower limb is in the extended position and when the 
patient is able to walk gives rise to the peculiar gait 
of the hemiplegic, for as the patient is able to flex 
the limb at the knee but slightly, he must, in order 
to progress, lift up that side of the pelvis (and with 
it the whole of the paralyzed limb) by contraction 
of the trunk muscles of the opposite side, at the same 
time turning the body on the sound leg. Hence he 
describes on the ground an arc of a circle with the 
paralyzed member, or, as the Germans put it, "he 
mows the ground." 

If, after three weeks or so, no contractures appear 
(and no exaggeration of the deep reflexes), complete 
restoration of voluntary power may be expected, the 
paralysis in such cases having been owing to indirect 
influence (pressure) and not to destructive action of 
the effused blood upon the motor tract. 

The muscles of the paralyzed parts waste somewhat, 



CEREBRAL HEMORRHAGE. 285 

but generally it is the wasting due to non-use, though 
in some cases the wasting is too rapid to be thus 
explained and must be attributed to the cerebral 
cause ; what part of the brain it is that has such 
trophic influence is not known (Groldscheider). The 
electrical reactions are normal or nearly so, the re- 
action of degeneration never occurring. The muscles 
that act in association on the two sides are not affected, 
but the trapezius at times shows some weakness in 
its upper part. The affected limbs are more or less 
cyanotic, are often somewhat swollen, while the palm 
of the contracted hand is moist from retained per- 
spiration. 

As late symptoms, secondary to hemiplegia, are 
seen at times certain associated movements in a para- 
lyzed limb when its fellow of the opposite side acts, 
and also posthemiplegic tremor, occasionally of the 
intentional variety. In children choreiform action, or 
athetosis (a continuous writhing movement of fingers 
and hand, or of fingers, hand and arm, occasionally 
of toes and foot) is present in many cases. 

When the site of cerebral haemorrhage is in the 
neighborhood of the large basal ganglia and the motor 
tract, hemiplegia must result, but haemorrhage may 
take place in any other part of the brain and then 
the symptoms will vary accordingly (vide Figs. 44 
and 45). 

Haemorrhages upon the cortex (vessels of the pia) 
must be very extensive to cause a hemiplegia, since 
the whole motor area would have to be subjected to 



286 THE BKA1N. 

the effused blood. As a matter of fact, complete 
hemiplegia from haemorrhage upon the cortex is rare, 
while a partial hemiplegia, especially of one limb or 
part, and begun with spasm, points to the cortex as 
the site of the lesion. 

The centrum semiovale is the site of haemorrhage 
less often than the internal capsule and basal ganglia ; 
the nearer to the cortex it is, the more nearly do the 
symptoms resemble those of the cortical lesion — and 
the deeper the haemorrhage, the more closely do they 
approach those of typical hemiplegia. 

Haemorrhages into the pons are less frequent than 
those of the cortex. If in the upper two-thirds, a 
typical hemiplegia may be caused ; if in the lower third, 
a crossed hemiplegia will result — i. e., paralysis of the 
limbs of the side opposite the lesion, the face being 
paralyzed on the same side as the lesion. When the 
haemorrhage is from a median branch of the basilar 
artery, as it most often is (Growers), its location is 
central, the apoplectic attack is ushered in generally 
with convulsions that are bilateral mostly, while all 
four limbs may be paralyzed. In pontine haemorrhages 
the danger of death is very great. 

At times haemorrhage in the neighborhood of a 
lateral ventricle breaks its way into the latter and 
from it the whole ventricular system may be invaded. 
The result will be a distinct and alarming aggravation 
of symptoms already present ; coma deepens or returns, 
the unaffected side becomes paralyzed and convulsed 
or even general convulsions may occur, tetanic rigidity 



CEREBRAL HAEMORRHAGE. 287 

being one mode of the latter. The prognosis be- 
comes absolutely hopeless, death occurring within a 
day or two. 

The sensory disturbances during an apoplectic attack 
already mentioned will, of course, be more marked 
the greater the invasion of the posterior part of the 
posterior limb of the internal capsule, and may be 
permanent ; pain may exist in the paralyzed limbs, 
either continuously or as painful hyperesthesia on 
being touched. 

Conjugate deviation of the eyes and head to one 
side is of some diagnostic value. If they are directed 
away from the paralyzed side it means a cerebral 
paralyzing lesion or a pontine irritative one ; if they 
are towards the paralyzed side, there are conditions 
of irritation in a cerebral lesion (cortical or possibly 
ventricular haemorrhage without irritation), or the lesion 
is in the pons and is paralyzing. 

The fate of the blood effused in cerebral haemor- 
rhage is, first, coagulation ; next, breaking down of 
the constituents of the clot ; then, absorption. Mean- 
while, the surrounding brain tissue sets up protective 
inflammatory changes in proliferation of glia cells 
and connective tissue, forming a capsule within which 
further absorption of the broken-up clot goes on, until 
finally the latter has disappeared and its place is taken 
by serous fluid, the result being a hemorrhagic cyst. 
In the case of quite small haemorrhages, the walls 
approximate and the space is bridged across by con- 
nective tissue, whose subsequent contraction results 



288 THE BEAIN. 

in the formation of an apoplectic cicatrix. Either 
process requires considerable time, the formation of a 
hemorrhagic cyst requiring at least three or four 
weeks (Oppenheim). 

Apoplexy from Vascular Occlusion.— 
Acute Encephalomalacia. 

When an artery is occluded in the brain, the tis- 
sues depending on it for their blood supply must die 
for want of nutrition, there being in the brain but 
little vascular anastomosis. The occlusion may be 
either from an embolus or a thrombus. 

An embolus, being a detached mass of fibrin in 
the arterial current, gets to a point beyond which 
in the narrowing vessel (usually where a branch is 
given off) the blood current cannot carry it. 

The source of the embolus is in most cases the 
heart itself, which, when diseased as by endocarditis, 
or with valvular trouble, has deposits within it of 
coagulated fibrin. Of the latter a fragment, if de- 
tached, is sent out in the blood current and is ar- 
rested as described above, in some small vessel. 
Emboli are at times carried by the blood-current 
from a thrombotic deposit in a diseased large blood 
vessel, or enter the heart from the venous side in 
cases of pulmonary gangrene, ulcerative bronchitis, etc. 

Thrombosis, being a deposit chiefly of fibrin in a 
vessel (excepting the capillaries) is due to alteration 
in the composition of the blood, or in the structure 



APOPLEXY FROM VASCULAR OCCLUSION. 289 

of the walls of the blood vessels. The latter is the 
most frequent cause of cerebral thrombosis, and is 
due to atheroma or to syphilitic endarteritis. Acute 
infectious diseases, exhausting chronic ones (phthisis, 
cancer, etc.) alter the blood's composition, and may 
cause thrombosis. 

Diagnosis between embolus and thrombosis of a 
brain artery is largely a matter of age, since an 
apoplexy in an individual past forty-five and without 
heart lesion is more likely due to thrombosis than 
to embolism. Apoplexy in persons under forty and 
without heart lesion is presumably due to occlusion 
from syphilitic endarteritis. Embolic occlusion is seen 
mostly in the young, and is but rarely repeated. 

The symptoms of apoplexy from embolism are 
similar to those from cerebral haemorrhage, but are 
less in intensity. Their onset is sudden and with- 
out prodromata ; those of thrombosis usually have 
prodromata, sometimes repeatedly during a long- 
period precedent to the apoplectic attack. Embo- 
lism affects most often the branches of the middle 
cerebral artery, and somewhat more frequently the left 
one than the right ; thrombosis has the same pre- 
dilection, but the arteries of the circle of Willis, 
the basilar and the internal carotid are not infre- 
quently the site of either form of obstruction, the 
thrombotic process, however, often extending to 
neighboring branches not at first affected, thus in- 
creasing the gravity of the condition. Syphilitic en- 
darteritis affects particularly the circle of Willis, but 



290 THE BRAIN. 

its larger branches, as well as the vessels leading 
to it, are often its victims. 

The brain tissue dependent upon the blood pre- 
viously supplied by a now occluded vessel dies and 
undergoes softening, unless there be collateral circu- 
lation. This is not possible, except on the cortex, 
and then in limited degree, and in the larger ves- 
sels leading to the circle of Willis. 

Softening has been classified as red, yellow and 
white, but the color in red softening is due to the 
presence of blood coloring matter, and is found in 
parts that are vascular in the normal state (such as 
the cortex) ; by decomposition and absorption of 
the blood pigment the red tint changes to yellow, 
and then the term yellow softening applies. In the 
white matter the softening is nearly white in tint. 
The consistency of the softened mass is semi-liquid, 
and after its complete absorption its site is repre- 
sented by a cicatrix generally, at times by a cyst. 

While the symptoms of an apoplexy from vas- 
cular occlusion are, in the main, those of a cerebral 
haemorrhage, yet there are differences that will suf- 
fice in most instances to determine to which class the 
case belongs. In the former the face is generally 
not turgid, the respiration less disturbed, the initial 
lowering of temperature seen in cases of haemorrhage 
is rarely present, while its rise will not be great 
when it does occur. Embolus occluding a brain 
artery is more apt to produce convulsive movements 
at times epileptiform in character, and, if the vessel 



APOPLEXY FROM VASCULAR OCCLUSION. 29 1 

involved be small, there may be no loss of conscious- 
ness. In thrombosis, even of a large vessel, there 
may be no loss of consciousness, or the latter may 
come on only after symptoms of hemiplegia. 

The symptoms from occlusion of a cerebral blood 
vessel are direct and indirect, and if collateral circu- 
lation be established (cortical, internal carotid, etc.), 
all the symptoms will disappear. Oppenheim holds 
that a thrombus may break down and be washed 
away in some cases, and thus explains transitory 
hemiplegia. The direct symptoms are those that re- 
main, and they are of the same value in localization 
as in the case of haemorrhage. 

Aphasia is more common in occluding lesions of 
the left hemisphere than in haemorrhage ; hemia- 
nopsia and hemianaesthesia are the results if the pos- 
terior cerebral is blocked up and no anastomotic cir- 
culation is possible (not common). 

The prognosis, so far as life is concerned, is more 
favorable in occlusion than in haemorrhage, as a 
general rule, but when coma is intense the danger 
is rather in its intensity than in its duration (Gowers), 
a moderate degree lasting several days being not in- 
frequently followed by recovery. Thrombosis of the 
basilar artery is almost always fatal, and next in fa- 
tality is that of the internal carotid. Danger to life 
increases with each succeeding attack of thrombotic 
occlusion, and in the thrombotic process there is 
great tendency to recurrence ; in embolism there is 
but little, while in syphilitic vascular disease recur- 



292 THE BRAIN. 

rencc must be expected if the disease be not ar- 
rested. 

Inflammatory reaction sets up around the softening 
tissue, and it is more severe than the corresponding 
process in cases of haemorrhage, and may give rise to 
severe cerebral complications, such as delirium, head- 
ache and convulsions, the latter at times a very un- 
favorable complication. 

If the paralytic symptoms, although not so great 
nor so extensive in acute softening as after haemor- 
rhage, do not disappear after two or three weeks 
have passed, they will be permanent. From throm- 
bosis there is distinct impairment of the mental 
faculties ; from embolism there is usually but little, 
or there may be none at all. 

The treatment of apoplexy consists in first placing 
the patient in the most advantageous posture. He 
should be put to bed and laid on the paralyzed side; 
the respiratory muscles of the sound side have thus 
the fullest freedom of action and stertor is said to 
thereby cease. Cold applications may be made to 
the head and warm ones to the extremities, mustard 
applications being advised by different authors. 

Treatment by drugs at this stage must be almost 
wholly symptomatic. The effect of even a small 
haemorrhage within the skull cavity is to set up irri- 
tability of the vaso-motor centres, and our remedies if 
chosen by the resultant symptoms, will quiet the 
vascular excitement. Belladonna, Glonoine, Melilotiis alba 
and Opium will be thought of at once. When the 



APOPLEXY FROM VASCULAR OCCLUSION. 293 

coma is profound, the stertorous breathing marked, the 
face dusky and the patient covered with sweat, Opium 
is the chief remedy. When the face is red and hot 
even if coma or stertor be present Belladonna should 
be prescribed; Glonoine and Veratrum viride resemble 
Belladonna very greatly, but the cardiac irregularity 
of the first and the more powerful pulse of the 
second may serve as points of difference. Jfelilotus alia 
ought to be of service in the early active stage. 

The foregoing remedies have been used by the 
writer in such cases in the third centesimal dilution, 
excepting Glonoine which had better be given in the 
sixth ; in cases of alarming character, the doses may 
be given every 15 minutes, but the intervals should 
be lessened as soon as improvement in the pulse or 
the respiration or the appearance is noted. 

When consciousness has been even partly restored, 
Arnica radix should be given in third dilution every 
two or three hours, a few doses only, after which 
the symptoms should be studied for special indica- 
tions and later, when inflammatory reaction has set 
up, the same method should be followed. 

In cerebral thrombosis but little can be done at 
the beginning, since the occlusion already present will 
extend, or if not absolute will soon become so. If 
as a result of the shock vascular symptoms set up, 
the remedies already mentioned will possibly be 
indicated, but Glonoine or Baryta muriatica will at once 
be thought of. Lachesis and Crotalus liorridus ought to 
be of value in combatting the reactionary inflammation 



294 THE BRAIN. 

and in keeping it within limits. Phosphorus and Sepia 
have been highly commended in this stage. 

Embolic occlusion, after it has occurred, cannot be 
remedied. Aconite followed by Arnica radix 3, ought 
to be of service in preventing too severe a reaction. 

For the hemiplegia or other paralysis following 
any form of apoplexy, Causticum, Cocculus, Nux vomica, 
Graphites, Baryta and Arnica are recommended by a 
number of observers. The writer has seen apparently 
remarkable results from Nux vomica, low, 2x, in hos- 
pital cases ; and in private practice, Baryta carbonica or 
muriatica. It must not be forgotten that the symptoms 
due to destructive changes in the motor area or motor 
tract cannot, according to present views, be relieved, 
and that the other or indirect symptoms can and do 
disappear without treatment. Nevertheless, the sec- 
ondary (indirect) symptoms may not disappear unless 
under the action of suitable remedies. 

The use of electricity has been greatly extolled in 
the treatment of hemiplegia and other paralyses of 
cerebral origin. As a means of keeping up the nutri- 
tion of the muscles of the paralyzed part faradism is of 
high value, and should the paralysis be only an in- 
direct symptom, its disappearance will then find the 
muscles ready and able to act. 

The employment of static electricity in relieving 
the secondary contractures in hemiplegia has been 
much vaunted; the writer has used it repeatedly with- 
out the slightest effect in such cases, although it hap- 
pened that the patients themselves were at first deceived 



BRAIN TUMOR. 295 

and believed they had received a greater power and free- 
dom of motion in the paralyzed limbs. Hemiplegics, 
like other paralytics, learn to use with greater adroit- 
ness such trifling power as may exist in the affected 
limbs, and thus may honestly believe that a cure is 
being effected. 

Brain Tumor. 

A growth in or upon the brain may irritate or 
destroy the parts adjacent to it, or may do both. It 
may therefore produce localizing symptoms. It also 
in most cases causes general ones which, taken to- 
gether, will justify the diagnosis of brain tumor. Such 
a mass is only a foreign body, the localizing symptoms 
being those depending upon its location, the general 
ones being largely due to pressure of the growing 
mass. The kind of tumor cannot be known from 
either set of symptoms but may often be determined 
by other information. 

The records of the autopsy table show that certain 
parts of the brain are places of election for certain 
kinds of tumor. Glioma may affect any part of the 
brain but selects first the cerebral hemispheres and 
next the cerebellum ; tubercle affects mostly the cere- 
bellum and next the pons; syphiloma is found oftenest 
at the base, next on the cortex in the central and 
pre-central regions, while it is rare on the cerebellum 
or in the white matter of the cerebrum. 

The existence of morbid growths elsewhere in the 



296 THE BRAIN. 

body would make it probable that a tumor of the 
brain is of the same nature. 

Age is at times of great help ; a brain tumor in a 
child is evidence that it is probably tubercular in 
character, while a tumor in a person of advanced 
years is more probably glioma (including sarcoma) than 
syphiloma, the reverse being the case in the young 
adult. 

The rate of progress in growth (as shown by in- 
creasing intensity of the symptoms) may be of cor- 
roborative value. Glioma grows slowly and being 
itself liable to haemorrhages may give rise to apoplectic 
attacks ; carcinoma grows rapidly but it is usually 
metastatic in origin, while syphiloma grows rapidly 
in one direction and at the same time breaks down 
in another, accounting thus for the changeability of 
its symptoms. 

The general symptoms of brain tumor usually pre- 
cede the appearance of the local ones. Headache 
exists in the great majority of cases ; it is mostly 
continuous, but has spells of aggravation. Its intensity 
is often frightful, and its character varies in different 
cases ; it is aggravated by forced exertion, stooping, 
coughing, etc. Its subjective location may be frontal, 
occipital, lateral or diffusely spread, but the subjective 
location is of no value in localizing the site of the 
tumor; the head is often sensitive to percussion with 
the fingers and at times extremely so in the neighbor- 
hood of the growth. 

Choked disk is considered by Oppenheim to be 



BRAIN TUMOR. 297 

characteristic of the existence of tumor, nine out of 
every ten cases of it being so caused. He differen- 
tiates the swollen choked disk from a simple optic 
neuritis, which also can exist as a result of brain 
tumor, but which is to be seen as well in other dis- 
eases. It has been observed that the vision, during 
the course of brain tumor, does not fail to the degree 
expected with such swelling and obliteration of the 
disk ; the vision does finally disappear if the patient 
live for a considerable time, the ophthalmoscope then 
usually revealing consecutive atrophy of the nerve. 

The mental state suffers generally during the course 
of a brain tumor, varying from slight loss of power 
of attention or concentration to an absolutely stupid 
condition, or apparently as if overcome by an opiate. 
Conditions of insanity develop quite often, mostly of 
the type of mania, occurring in paroxysms, or at times 
of hallucinatory insanity or melancholia, but more often 
the mental change is evidenced by silly, foolish behavior 
— in one case the writer has seen marked hysterical 
manifestations. Growths at the base or distant from 
the frontal lobes, and tumors of small size, are not so 
apt to cause psychical change. 

Vertigo is frequently an accompaniment of brain 
tumor ; if violent it becomes a localizing symptom. 
It is not attended by nausea, generally. Vomiting, 
projectile in character, is noted in the majority of 
cases ; if associated with headache, as it often is, it 
may give rise to the erroneous diagnosis of migraine. 

Slowness of the pulse is observed when intra-cranial 



298 THE BRAIN. 

pressure becomes considerable ; it is not an early 
symptom unless the structures beneath the floor of 
the fourth ventricle become implicated, and then it 
has a localizing value. 

Attacks of convulsions with or without loss of con- 
sciousness, or of the latter alone, or of temporary 
blindness, are among the less frequent general mani- 
festations. 

Localizing symptoms vary with the site of the 
tumor ; they may be irritative in character, or para- 
lyzing, most often the latter. The symptoms are often 
indirectly produced, especially when intra-cranial pres- 
sure is great. 

Tumors of the frontal lobes are apt to cause marked 
mental changes already mentioned; if left-sided, motor 
aphasia will be present when the motor speech area 
becomes affected ; if riglrt-sided there may be no local- 
izing symptoms. 

Tumors involving the central convolutions are apt 
to cause motor irritative symptoms in the beginning, 
such as spasm in one definite part of the body; the 
spasm is repeated at varying intervals, and in time 
paralysis of the part (monoplegia of face or arm or 
leg) comes on. General convulsions may result, epi- 
leptic in character, but beginning in the same definite 
part (Jacksonian epilepsy). With the growth of the 
tumor the paralysis spreads until a hemiplegia is pro- 
duced, with strong tendency to contractures. In most 
cases there is some hypsesthesia or paresthesia in the 
paralyzed side. 



BRAIN TUMOR. 299 

Tumors affecting the cortex behind the motor areas 
must interfere with the muscular sense, and, if in the 
neighborhood of the supramarginal and angular gyri 
of left hemisphere, will cause alexia. 

Tumors in the occipital lobe, if involving the cortex 
adjoining the calcarine fissure, will produce homony- 
mous hemianopsia; if affecting the outer face of the 
occipital lobe, especially the angular gyrus, there may 
be loss of the memories of the uses of things pre- 
viously well known, such as the objects seen in 
everyday life ; this condition is known as psychical 
blindness. If the tumor involve the anterior area, 
it may encroach on the angular and supramarginal 
gyri, with the result of causing alexia, if on the left 
side. Hemianopsia is also caused when the tumor 
affects the white matter of the occipital lobe, since 
the optic radiations will be affected. 

Tumors of the temporal lobe, if left-sided and in- 
volving the auditory speech area, cause word-deafness 
with paraphasia; otherwise such tumors of either side 
cause no direct symptoms. 

Tumors of the centrum semiovale are not specially 
characterized by their symptoms, but the nearer they 
are to the cortex the more will cortical symptoms 
appear; hemiplegia of gradual onset is considered to 
be symptomatic, while, if the corpus callosum be 
specially implicated, extension of the growth will 
probably cause paraplegia. Tumors of the corpus 
callosum are also believed to cause a marked stupidity, 
apathy or soporous condition. (See Fig. 45, page 261.) 



300 THE BRAIN. 

Tumor at the base can hardly help affecting some 
of the cranial nerves. If in the anterior fossa it is 
likely to affect by pressure the olfactory and optic 
nerves and, by extension of pressure, the third nerve 
and first branch of the fifth. If upon the sella 
turcica, the optic chiasm, the hypophysis, the nerves 
of the orbit and the first branch of the fifth; if in 
the lateral cavity of the middle fossa, all branches 
of the fifth may be affected and also the ocular nerves. 

Tumors of the posterior fossa will by pressure affect 
the nerves arising from the pons and medulla ob- 
longata, directly or indirectly, except the twelfth 
nerve, which by its low point of emergence may 
escape direct pressure. 

Tumor affecting one crus cerebri will usually cause 
hemiplegia of the opposite side, with third nerve paraly- 
sis of the same side. (See Fig. 38, page 236.) 

Tumor in the corpora quadrigemina and the struc- 
tures just below it, causes ataxia and paralyses of the 
eyeball muscles ; the ataxia is of the cerebellar variety. 

Tumors of the pons and medulla are infrequent. 
If limited to one side of the pons, a tumor may 
cause hemiplegia of the opposite side of the body, 
when it is above the middle ; if below the middle, it 
will probably cause alternating hemir>Legia, that is, 
paralysis of arm and leg of opposite side with paraly- 
sis of the face on same side, and the latter may show 
degenerative reaction. If the tumor is low down in 
the pons, the face escapes. Tumor in the medulla or 



BRAIN TUMOR. 301 

pons, involving the neighborhood of the sixth nerve 
nucleus, will cause paralysis of that nerve, and there 
is then often conjugate deviation of the eves to the 
other side. (See Fig. 38, page 236.) 

Tumor in the medulla, if on one side, will cause 
incomplete hemiplegia, arm and leg of opposite side 
being affected, but with paralysis of the tongue on 
the side of the lesion. If the growth involve both 
halves of the medidla, the symptoms will be those 
of bulbar paralysis with, possibly, paralysis of the 
four limbs. If it invade the fibres forming the in- 
ferior peduncle (medulla), or those of the middle 
peduncle (pons) of the cerebellum, ataxia, cerebellar 
in character, is to be expected. 

The direct symptoms of tumor of the cerebellum are 
occipital headache, extending at times to the nape and 
even lower, vertigo, and cerebellar ataxia. The 
ataxia disappears when the patient is lying down ; 
when up and walking about it is a reeling gait, or 
if slight, it is as if he were in fear of falling ; the 
ataxia does not affect the arms. The forced move- 
ments seen in cerebellar troubles, turning continually 
to one side when lying, or going to one side when 
walking, cannot as yet be positively ascribed to disease 
of any definite part of the cerebellum, although both are 
cerebellar symptoms ; they have been noticed in con- 
nection with involvement of the middle peduncle of 
the cerebellum. Tumors of the middle lobe of the 
cerebellum, if growing downward, will by pressing 
upon the floor of the fourth ventricle give rise to 



3<D2 THE BRAIN. 

either irritative or paralyzing conditions in the nerve 
nuclei and nerve centres below. 

The connections of the cerebellum with other parts 
of the brain and cord are large peduncles ; a tumor 
may, by pressure on one, draw upon and possibly 
displace some other structure, and so give rise to 
confusing indirect symptoms ; the eifect of a tumor 
anywhere in the brain is at times greater in this 
displacing result than by its direct action in its own 
site. 

Vomiting is a symptom of cerebellar tumor 
very frequently seen, but is not necessarily a direct 
one. Nystagmus is at times a symptom of cere- 
bellar tumor, due probably to distant effect on the 
quadrigeminal region ; internal hydrocephalus is at 
times observed, a direct result of pressure on the 
vena magna Galeni, with consequent damming back 
of the circulation. 

Diagnosis. Some of the general symptoms of 
brain tumor occur with other disease processes. 
Severe optic neuritis may occur with nephritis, with 
meningitis, and even with hydrocephalus, while head- 
ache can exist in all of these ; the microscope, the 
history, progress and special symptoms will serve for 
differentiation. Abscess of the brain rarely causes 
choked disk, and generally there is an etiological 
factor present (ear-disease, suppuration elsewhere, in- 
jury to the head). Poisoning by lead may cause 
choked disk, headache, delirium and convulsions, but 
these are preceded by other evidences of the poison. 



BRAIN TUMOR. 303 

Profound anaemia may cause headache, and even 
choked disk; here the existence of the cause, as 
well as its relief by treatment, wall clear up any 
doubt. 

Chronic alcoholism may cause optic neuritis, head- 
ache, etc., but the optic affection is characterized by 
central scotoma for colors and the alcoholic tremor is 
present. Hysteria at times presents a functional hemi- 
plegia, with headache that might lead to doubt ; the 
headache is relieved by emotional influences, yet it is 
not rare for hysterical symptoms of marked type to 
appear during the progress of brain tumor. Syph- 
ilitic meningitis is especially apt to appear at the 
base and give rise to the symptoms rjroduced by a 
tumor in that situation. 

The operative treatment of brain tumor has been 
the subject of great attention. The indications for it 
have become sufficiently definite to be tabulated 
through the experience of v. Bergmann, Horsley, and 
others. 

The tumor must be susceptible of accurate localiza- 
tion ; its location must be accessible to the surgeon ; it 
must be near the surface ; it must be limited in out- 
line, or at least not diffuse or infiltrating in its mode 
of growth. The surgeon is thus limited practically to 
tumors in or upon the motor area and the lower 
parietal area. 

The earlier an operation can be done, the better. 
In cases not suitable for operation for removal of 
the growth, trephining with opening of the dura will 



304 THE BRAIN. 

relieve brain pressure, and so relieve many of the 
symptoms. 

Intracranial aneurism of a large vessel acts upon 
the nervous structures by pressure, and is to all in- 
tents and purposes a brain tumor. The exciting 
causes are a previous embolus of infectious char- 
acter, which sets up inflammation in the vessel's 
wall with subsequent yielding; syphilitic disease of 
the arteries ; primary arterio-degeneration in later 
life and (rarely) injury to the head. 

The arteries of the brain most frequently af- 
fected by aneurism are the middle cerebral, basilar 
and internal carotid. In two-thirds of the cases of 
aneurism one of these three vessels is the seat of 
the disease (Gowers). Much less frequently af- 
fected are the anterior cerebral, posterior communi- 
cating, anterior communicating, vertebral, posterior 
cerebral and inferior cerebellar — the last two very 
rarely. 

The diagnosis is extremely difficult, and is often 
impossible. In rare cases it becomes certain when 
a bruit can be heard on auscultating the skull. 
The symptoms being those of a tumor at the base, 
aneurism may be suspected if a lesion can be lo- 
cated in the neighborhood of the great vessels and 
the patient have general arterial disease or organic 
cardiac affection. 

The prognosis, when the diagnosis of aneurism 
has been made, becomes very gloomy, since rupture 
may occur at any time ; rupture does not neces- 



BRAIN TUMOR. 305 

sarily occur, and when it does, is not necessarily 
fatal. 

The treatment of tumor of the brain by homoeo- 
pathy has been considered at length by the writer 
in Hahnemannian Monthly, 1896. As the symptoms 
are those due to pressure upon and irritation of 
different parts of the brain by the growth, the 
latter is practically the same as a foreign body, 
and if possible, it should, as in the latter case, be 
removed mechanically. To administer remedies se- 
lected according to the symptoms caused by the 
pressure upon and irritation of the invaded struc- 
tures is only to help those structures tolerate bet- 
ter such interference. The time may come when 
by homoeopathic medication morbid growths may be 
made to retrogress ; until that time, brain tumor 
must be considered as not the subject of homoeo- 
pathic treatment. Palliative and antipathic measures 
will have to be employed; potassium iodide in or- 
dinary doses in some cases has given considerable 
relief for a time. Trephining the skull has been 
resorted to for relief of intracranial pressure and 
with success, in one case even to retrogression ot 
optic neuritis. 

Intracranial aneurism will be best treated by the 
use of Baryta muriatica and Plumbum in persons not 
syphilitic. The general symptoms may call for any 
other drug and such should be given. In cases 
having a syphilitic history, Mercurius protoiodatus 2x, 
or if much mercury have already been taken, 



306 THE BE A IN. 

Aurum muriaticum natronatum 6x may be of value. 
In any case the writer would give in addition a 
nightly dose of Syphilinum 200 or higher for a 
month, repeating the prescription after an interval 
of a week or two. 

Brain Syphilis. The effects of the malign influence 
of the microbe of syphilis (or of its toxine) within 
the skull cavity, are chiefly upon the meninges and 
the walls of the blood vessels. The most common 
manifestation is chronic gummatous meningitis situated 
at the base and especially in the intercrural space and 
extending over the chiasm. The process results in 
an exudation of gummatous material, alteration of the 
blood vessels and injury, partly by compression, partly 
by invasion, of the nerves. The symptoms are there- 
fore those of a basal meningitis with special implica- 
tion of the optic nerve and the motor nerves to the 
eyeball. Other nerves are at times affected. 

With the inflammatory changes mentioned the ar- 
teries are also involved, the walls being thickened 
and their lumina narrowed, often resulting in throm- 
botic occlusion. 

Next in frequency is gummatous meningitis of the 
convexity, involving more or less the cortex and then 
giving rise to wide-spread softening. 

The gummy exudation may be in masses of vary- 
ing size and thus act as tumors, but the tendency to 
fatty degeneration and caseation is very great and 
leads to a changeability in the symptoms at times 
surprisingly rapid. Implication of the middle of the 



BRAIN SYPHILIS. 30/ 

chiasm will cause bi-temporal hemianopsia, but vary- 
ing changes in the visual field point to the syphilitic 
character of the affection. Similar instances are the 
receding of a third nerve paralysis until it has dis- 
appeared, perhaps to recur in a few days. 

The intra-arterial proliferation is characterized by 
great permanency, and occlusion of the proper artery 
will cause a typical hemiplegia. 

It is not infrequently preceded by several light 
apoplectic attacks, with hemiplegia lasting from a few 
minutes to a few days. 

Endarteritis of the basilar or vertebral artery can 
give rise to bulbar symptoms, but such symptoms may 
occur if an exudation extends as far backward as the 
pons and medulla. 

The general symptoms of chronic gummatous me- 
ningitis are headache, vertigo, vomiting, attacks of 
mental confusion or of mental incapacity : in some 
cases excitement. Polydipsia and polyuria are often 
present. The headache is at times of great intensity 
and is often, but not always, worse at night. Its 
cessation may deceive the unwary physician into be- 
lieving that he has relieved it, but it frequently ceases 
just before a paralysis occurs, such as hemiplegia, 
paralysis of eye muscles, etc. 

Optic neuritis or even choked disk occurs in more 
than two-thirds of the cases, but not always on both 
sides. 

The diagnosis of brain syphilis may often be made 
without any history, by noting the changeability of 



308 THE BRAIN. 

the symptoms, their coming and going, their multi- 
plicity. When, in addition to these points, evidences 
of a previous general adenitis, (post-cervical, epitroch- 
lear or inguinal glands) or atrophic scars on face, 
legs, etc., if present, relieve us of the necessity of 
questioning too closely an unwilling patient. A mar- 
ried woman with no suspicion of the cause of her 
head symptoms may be questioned about early mis- 
carriages, still-born children, infant born with eruption 
around the anus and suffering from snuffles, etc. ; her 
affirmative answers will tell the story. 

The treatment of brain syphilis has been given 
under the head of brain tumor. 

Cerebral Infantile Paralyses. Spastic Infantile 
Paraplegia. The cerebral paralyses of children are 
most often determined by disease or injury to the 
brain during the first few years of extra-uterine life 
next in frequency during parturition, and least during 
intra-uterine life. 

Of the first, the greater number occur during the 
course of the acute infectious diseases or possibly by 
an infection sui generis, or as the result of traumatism 
upon the head. 

The second includes those where the act of parturi- 
tion is difficult and prolonged, especially when the 
forceps have been used, not because the instrument 
was applied but because of the conditions demanding 
it. The result of the great pressure is meningeal 
haemorrhage usually over the upper parts of both 
motor areas, or direct injury to both these areas by 



CEREBRAL INFANTILE PARALYSES. 309 

pressure of the yielding parietal bones. The conse- 
quence is then not hemiplegia but paraplegia. 

The third kind, beginning during intra-uterine life, 
has been attributed to different causes, chiefly to in- 
jury to the mother during pregnancy (especially injury 
affecting the uterus), occasionally to severe emotional 
shock, and to disease affecting the fcetal brain and 
resulting in faulty development, particularly of the 
central convolutions. 

The symptoms of the first class occur in the majority 
of cases during the first few years of childhood as 
an acute attack of fever accompanied by headache, 
vomiting and general convulsions ; in some cases the 
convulsions may be confined to one side ; the con- 
vulsions may be repeated or may be absent. The 
symptoms of the acute stage may continue a day or 
two, or may last a week or more. When this stage 
has passed it is noticed that the child is paralyzed, 
the symptoms being those of hemiplegia with but tem- 
porary implication of the face ; in children who can 
talk there may be temporary aphasia. Sensibility is 
usually not disturbed. In the course of time some 
improvement is manifested in the paralyzed limbs, 
but the rate of growth is less rapid than in those 
of the sound side. Meanwhile, contractures of the 
flexors and adductors come on which are, in the arm 
like those of an ordinary hemiplegia, but in the leg 
the typical hemiplegic gait is absent, because there 
is some flexion at the knee. Or, certain spasmodic 
movements, athetosis or chorea, appear in the affected 



3IO THE BRAIN. 

arm and hand especially, or associated movements 
occur in the affected side when movement is attempted 
by the sound side. The knee-jerk is usually exagger- 
ated and ankle clonus can generally be elicited. 

In a large number of the cases epilepsy develops 
in course of time, occasionally continuing from the 
termination of the acute stage. 

The mental development is nearly always affected 
in some degree, from mere slowness of perception 
to imbecility or even idiocy. 

The second class, arising from injury during birth, 
generally show on coming into the world evidences 
of severe pressure upon the head, and cyanosis, while 
the history tells us that the accoucheur had difficulty 
in bringing the infant "to life." Convulsions may be 
present at this time but often cease, to return some 
weeks or months later. The child does not develop 
as it should ; it is found that it does not use the 
limbs of either side and that both trunk and neck 
muscles are affected, since it cannot hold the head 
up nor sit if unsupported. This condition is a double 
hemiplegia and indicates extensive injury to both motor- 
areas. When, as frequently happens, the upper por- 
tions only of the motor areas have been involved, 
the effect is seen only in the lower extremities and 
the condition is a spastic cerebral paraplegia. Some 
rigidity and contractures appear. When attempts are 
made to teach the child to walk it refuses to put its 
feet to the floor, indeed draws them up and when it 
does learn to take some steps (by assistance) the ad- 



CEREBRAL INFANTILE PARALYSES. 3 1 1 

ductor muscles of the thighs are seen to be contracted, 
sometimes to the extent of crossing the legs. Should 
this condition remain, the child when able to walk 
does so by " cross-legged progression." Mental defect 
is common in this form and epilepsy may be expected 
to develop. 

The third class of cases, those due to intra-uterine 
causes, are usually double hemiplegias having the 
symptoms of the first class without the acute stage, 
fever, etc. The mobile spasms, or choreic movements, 
are the same, but the mental impairment is, of course, 
much greater. Epilepsy develops in a majority of the 
cases. 

The differentiation of the three types of cerebral 
palsy in children is partly a matter of the history, 
partly one of examination. 

A child having been perfectly well up to, say, the 
third year, without history of injury already described 
at the time of birth, and without any evidence of faulty 
development in utero (such as abnormalities in the 
shape or size of the skull, gothic palate, etc.), is then 
attacked by an acute affection following the course 
and having the sequelae already stated. The only con- 
clusion to be drawn is that the affection is acute 
encephalitis. When evidences of faulty intra-uterine 
development are present, the case belongs in all proba- 
bility to the third class, though by no means all of 
this class show such evidence. 

The history of difficult labor, the child being as- 
phyxiated when born, will classify the remaining cases; 



3 1 2 THE BRAIN. 

the history of the condition at birth cannot always 
be obtained. 

The lesions in the cases that are intra-uterine in 
origin, or which are caused at the time of birth, 
result in agenesis of the motor (and other in some 
instances) cortical areas, and agenesis of the motor 
tracts. The motor convolutions do not develop and 
their shrunken remains are at the bottom of a narrow 
fossa at the site of the Rolandic fissure and may open 
into the lateral ventricle. This condition is known as 
porencephaly. The gap may be filled by a cyst. 

In the hemiplegic cases, porencephaly of one hemi- 
sphere may exist or partial atrophy and shrinking of 
the central convolutions, with consequent degeneration 
of the pyramidal tract; at times the cortical areas 
show but little gross change and these are the cases 
in which epilepsy develops later with little or no motor 
disturbance. 

It has been already stated that in these forms of 
brain trouble the mentality is more or less affected. 
The child may be absolutely idiotic, may be imbecile, 
or may be only backward, the condition not being 
observable until its deficiency is remarked when 
compared with the average child of the same age. 
Many do not learn to talk until very late ; some never 
learn. Epilepsy develops in about half of the first 
form and in more than half of the others. 

Cruelty to others and destructiveness in general are 
often seen when the mental development is low. In 
some cases the children have some special habit of 



CEREBKAL INFANTILE PARALYSES. 3 1 3 

self-injury, as beating the head with the closed fist, 
or knocking it against the floor, so that the tissues of 
forehead or occiput are kept constantly bruised. 

The diagnosis of cerebral palsy in early infancy is 
not difficult ; the increased reflexes and absence of 
reaction of degeneration distinguish it from paralysis 
following poliomyelitis, with which it might possibly 
be confounded. 

Prognosis. In the first form, if the mental develop- 
ment has not suffered beyond a slight degree, the 
hemiplegia gradually lessens or may practically dis- 
appear, and the individual may attain adult age with, 
it may be, some peculiarity of gait or some asymmetry 
of the limbs of the two sides. In the second and 
third forms, the injury to the brain is relatively great, 
and when mental development is poor and especially 
if spasms occur, the prognosis for life beyond the 
period of puberty is not good. 

Treatment of the cerebral palsies of children must 
be educational, hygienic and medicinal. If the child 
is unable to talk, the writer recommends that it be 
placed in some hospital for children, and believes that 
from this association with many children the latent 
cortical areas for speech will be aroused into activity 
sooner than through teaching by adults. 

When the child has practically no power over its 
limbs and yet its mental state is not injured to a very 
great degree, the writer employs faradism to the un- 
used members, causing contractions of the muscles 
of the extensor side, and acting upon single muscles. 



314 THE BRAIN. 

Not only does this stimulate the growth of the muscles r 
but it also, he believes, teaches the child's brain how 
to act upon them. 

Cases that are imbecile or worse, need the care 
of an attendant and cannot be taken in a hospital. 
They should be sent to some institution for the care 
of feeble-minded children. To care for such cases at 
home is a trying task to the parents, unless they are 
able to keep a special attendant for the child. The 
home care of such a patient is apt to develop many 
of the emotional defects so often seen in later years. 

Surgical interference may be advisable in cases of 
old contracture, and braces and similar appliances may 
enable the child to walk. In such matters, each case 
must be taken by itself and treated accordingly. 

The remedies applicable in cases of cerebral infan- 
tile paralysis will vary according to the associated 
conditions of spasm, feeble mental development, 
mutism, etc. The writer has used Baryta carb. and 
Natrum mur. in the hope of developing such parts 
of the cortex as were not wholly beyond such possi- 
bility. Other remedies were used from time to time, 
according to special indications, among these Sulphur, 
Calcarea carb., Psorinum and Silicea being preferred. 
In cases without spasms, many relative cures have thus 
been made, and some absolute ones, but it is im- 
possible to say how much was done by the educational 
influences already mentioned, and how much by the 
remedies administered. 

The epileptic cases have in some instances been 



ACROMEGALY. 315 

greatly improved, Belladonna, Hyoscyamiis, Cicuia virosa, 
Cuprum aceticum and Cypripedium pubescens 3, having 
been the chief remedies employed ; the latter has 
been found of especial value in lessening the irrita- 
bility of the cortex in cases having many minor seiz- 
ures, apparently provoked by some trifling error in 
diet, a slight cold, etc. 

Acromegaly. As the name implies, the symptoms 
of acromegaly are most noticeable as enlargements 
of the ends of the body, the hands and feet, especially 
the fingers and toes, but also the nose, lower jaw, 
lower lip and tongue. Besides these, the clavicles, the 
sternum, and the upper vertebrae show enlargement 
and deformity, the latter being a kyphosis or kypho- 
scoliosis of the cervico-dorsal region. 

The disease begins in early adult life, usually be- 
tween the ages of 20 and 30, with paresthesias or 
slight rheumatic pains in hands and feet. Gradually 
the hands and feet enlarge, as well as the parts 
above mentioned. The enlargement appears to affect 
all the structures, but especially the bones, which 
become thickened rather than elongated. 

The patients become apathetic, sleepy, at times 
stupid, and complain of great weakness. In women 
the menses cease early in the disease, and the uterus 
is often atrophied. In men there is weakness or loss 
of the sexual power. 

The chest becomes deepened, with kyphosis at the 
upper vertebras ; there may be an associated and 
compensatory lordosis in the dorso-lumbar region. 



3 1 6 THE BRAIN. 

Hemianopsia, most often bi-temporal, has been repeat- 
edly observed, and occasionally optic neuritis. 

Heredity plays no part in the disease ; trauma has 
been given as the exciting cause ; inhalation of il- 
luminating gas (to unconsciousness) was followed in one 
case by the appearance of the disease, and it has been 
stated that several cases have followed removal of the 
ovaries. The post-mortem findings have been various. 
Persistence of the thymus gland, enlargement or 
smallness of the thyroid, have been noted, but far 
more often, growths in the vicinity of the hypophysis 
cerebri, or tumor or degeneration of that body, so 
often, indeed, that the pituitary gland is now con- 
sidered to be, when diseased, the cause of acrome- 
galy. The function of the gland being unknown, a 
theory of its influence in causing acromegaly cannot 
as yet be made, but hemianopsia, optic neuritis, and 
some of the cerebral symptoms may be explained as 
the result of pressure on the chiasm or optic tracts, 
the crura cerebri, or even on the carotids. 

The course of the disease is slowly progressive, but 
in many cases after reaching a certain height it ceases 
to advance. 

The diagnosis is to be made from the condition 
of giant growth, which is an anomaly of development 
and is without the disproportionate enlargement of hands, 
feet and chin (such cases seem to have a disposition 
to general dystrophies, particularly acromegaly. M. 
Sternberg, Zeitschr. f. klin. Med. Bd. XXVII.) ; from 
a very similarly appearing disease described by Marie 



THE CEREBELLUM. 3 I J 

and termed hypertrophic pulmonary osteo-arthropathy, 
in which the presence of a pulmonary or pleural af- 
fection, the knobbed ends of the distal phalanges of 
fingers and toes, with fragile and deformed nails, serve 
for differentiation. 

Homoeopathic treatment must be guided by the 
totality of the symptoms. In a case of the writer's, 
reported in N. A. J. of Homoeopathy, 1888, improve- 
ment in the general symptoms (mental and physical 
hebetude, etc.) followed the use of Sulphur and 
Silicea. 



The Cerebellum 

Consists of two hemispheres and a middle lobe known 
as the vermis. Its external layer is gray matter ar- 
ranged in more or less parallel narrow convolutions ; 
the fissures extending deeply, and branching by shal- 
low sulci give a foliated appearance to a section of 
a hemisphere. On both the upper and lower as- 
pects of the hemisphere distinct lobes are evident. 
The gray matter of the cerebellar hemisphere is 
in relatively greater amount than in the cerebrum. 

The middle lobe or vermis is divisible into a num- 
ber of parts ; the sulci are deep, but give off shallow 
branchings. The gray matter of the vermis is rela- 
tively small in amount. 

Within the white matter of each hemisphere, near 
its junction with the middle lobe, is a hollow gray 
body similar in appearance on cross section to that 



3 1 8 THE BRAIN. 

of the olivary body in the medulla oblongata. It is 
termed the corpus dentatum. Near the latter, towards 
the middle lobe, is a small nuclear mass, the emboli- 
form nucleus, and still further towards the median line 
another, the globose nucleus. 

The gray cortex of the cerebellum is made up of 
three layers, an outer or molecular, and an inner or 
granular one, while between them is the layer of large 
cells, the cells of Purkinje. Their dendrites are noted 
for the immense number of branchings directed out- 
ward, while the neuraxones pass inward. 

Practically very little is known of the functions 
of the cerebellum. Its connections with the cerebral 
cortex via interpolated gray nuclear masses in the 
pons (middle peduncle); with the spinal cord via the 
restiform body (inferior peduncle) ; and with the sub- 
thalamic region via the red nucleus of the tegmentum 
(superior peduncle), show its functions to be various 
and important. All, however, seem to be centred in 
the middle lobe, for removal of a cerebellar hemi- 
sphere is not followed by any characteristic symptoms. 

Disease of the middle lobe (or indirect action upon 
it) causes cerebellar ataxia, attacks of vertigo (es- 
pecially the feeling as if being rapidly rotated), and 
at times a disturbance of speech like the " scanning" 
speech. 

Slowly destructive lesion of the middle peduncle 
can progress without giving rise to symptoms. Irri- 
tative lesion often causes compulsory movement of 



HEADACHE. 319 

the body — in walking, going to one side ; in lying, 
turning on the long axis of the body. 

Nystagmus has been repeatedly noted in the course 
of cerebellar disease (the superior peduncle has direct 
relation to the red nucleus which is in the neighbor- 
hood of the rootlets of the third nerve). Symptoms 
from pressure or irritation of neighboring structures 
occur at times in the course of cerebellar disease, 
especially the cranial nerves, whose nuclei are in the 
pons and medulla. The corpora quadrigemina may be 
thus affected and bilateral ophthalmoplegia (exterior 
eyeball muscles only) appear, preceded by cerebellar 
ataxia. If the ataxia follow ophthalmoplegia the lesion 
is of the corpora quadrigemina. 

Choked disk is a very frequent accompaniment of 
cerebellar tumor. 

Hemiplegia may be caused by cerebellar tumor; it 
may be on the side of the lesion or the reverse, 
according as the site of the growth is below or above 
the decussation of the pyramids. 

Treatment of cerebellar disease will be found under 
Brain Tumor and Abscess of the Brain. 

Headache.— Cephalalgia. 

Headache is a very common affection and may pro- 
ceed from the most diverse causes. It is well known 
as one of the manifestations of cerebral congestion, 
meningitis, brain tumor, etc., of the infectious dis- 
eases, of poisoning by alcohol, lead, nicotine, etc., of 
ansemia, of aortic valvular disease, of nephritis, of 



320 THE BEAIN. 

constipation, etc. It may be caused reflexly by in- 
digestion, intestinal disease, uterine disease, by dis- 
ease of the naso-pharynx, catarrh of the frontal sin- 
uses, disease of the middle ear, uncorrected errors of 
refraction and faulty balance of the eye-ball muscles. 

Besides these and other symptomatic and reflex 
headaches in some, no such cause can be assigned or 
at least traced ; they are apparently a constitutional 
neurosis, since heredity often has a part in their ex- 
istence. 

The diagnosis of the different forms of headache 
requires a thorough examination in all directions in 
order to ascertain the cause. Tolle causam must be 
the watchword when undertaking the treatment of 
the disorder, and when possible to follow the injunc- 
tion the success resulting is in the highest degree 
gratifying. 

Headache is located within the skull cavity and 
must be distinguished from neuralgic or rheumatic 
pains in the tissues external to the bones ; frequently the 
two conditions are combined. The ache is generally 
diffuse, but often is concentrated or limited to certain 
regions ; predominant are frontal, temporal, occipital 
and vertex regions as locations of headache, and at- 
tempts have been made to connect the location of 
the ache with some special causal condition acting 
either directly (toxic) or reflexly. 

The treatment of headache must include first the 
removal of its cause by mechanical, surgical and hy- 
gienic methods, the correction of errors of refraction 



HEADACHE. 321 

or other ocular troubles, etc. ; next, the selection of 
a remedy based upon all the symptoms of the patient, 
especial prominence being given to the conditions of 
aggravation and amelioration, the character of the pain, 
its site, etc. To give here all the remedies that have 
caused headache in the provers would require many 
pages, while a mere repetition of the names of those that 
have been frequently beneficial in the condition would 
be of no practical value. In Lee's Repertory of Char- 
acteristic Symptoms under the rubric, headache, un- 
defined, 230 remedies are given; while the sub-rubrics 
of the different modalities, location of pain, etc., have 
considerably more than 200, some of them with but 
one remedy, others 50 or more. 

To write down all the peculiarities of the headache 
and to take time to study out the remedy, will give 
far better results than to prescribe off-hand from one's 
memory of the materia medica. 

When a remedy thus studied out relieves one attack 
and fails in the second or third, the writer takes this to 
be evidence of some distant cause. Even in such case 
our remedies will in the long run do better for the 
patient than the antipathic or palliative treatment by the 
coal-tar products, or the older sedatives and hypnotics. 
Thus a case of recurrent headache during many years 
was examined at different times for a possible cause. 
Eyes, ears, nasal passages, pelvic organs, etc., were 
thoroughly examined without finding anything whose 
correction relieved. The peculiarity of the headache 
was an accompanying dull ache in the abdomen. On 



322 THE BRAIN. 

this peculiarity Conium maculatum was prescribed and 
with almost immediate relief. 

A second time it relieved, but afterwards it failed 
utterly. Then, Cinnabar was given with great benefit 
at first, but later it was useless. In Lee's Repertory 
38 remedies are given for the combined abdominal 
and cephalic pain ; most of them had other symptoms 
contraindicating their employment in the case. For 
several years the patient has been greatly benefited 
by the use of Dioscorea (one of the 38), the attacks 
being generally lightened and frequently cut short — 
the dose is a few No. 10 pellets saturated with the 
tincture, repeated every few hours until some relief 
is felt. In the same case acetanilide, antipyrine and 
phenacetine have been used with either no result at 
all, or if improvement occurred it lasted only as 
long as the drug was present in the system, the head- 
ache returning the next day. 

Vertigo. 

Vertigo is the sensation of instability in the sub- 
ject, or the false appearance of motion of external 
objects, or both. It is a symptom arising from 
many causes and is found in organic disease of the 
brain, especially tumor of the cerebellum, in cerebral 
hyperemia, anaemia, arterio-sclerosis ; in altered com- 
position of the blood by toxic influences occurring in 
dyspepsia, constipation, and uraemia; by poisons in- 
troduced from without, the chief ones in every-day 
life being alcohol and nicotine ; with disease of the 



VERTIGO. 323 

inner ear (semi-circular canals), occlusion of the 
Eustachian tube, even a mass of cerumen pressing on 
the tympanic membrane ; from the faulty projection 
of objects in paralysis of eye-ball muscles. 

Vertigo may be a symptom of neurasthenia and it 
may be the equivalent of an epileptic spasm. 

The attack comes suddenly, lasts a very short while; 
the sensation is as if the sufferer were whirling or 
as if the ground were waving, or rising, or falling. 
In many cases the patient feels the contents of the 
cranial cavity to be whirling or " seething". The 
attack is often accompanied by faintness, mental con- 
fusion or even syncope ; nausea and vomiting are fre- 
quently observed. 

In a person subject to vertigo, an attack may be 
brought on by a sudden change from the lying to 
the sitting posture, by turning around suddenly or by 
stooping. 

In old persons with arterial changes vertigo may 
be a forerunner of apoplexy. 

The treatment of vertigo must be that of its under- 
lying cause when such can be discovered. In many 
cases the cause can only be assumed, but in any 
case the remedy is to be selected only after study 
of all the conditions and concomitants. In the Symp- 
tom Register to the Encyclopedia more than 400 drugs 
have vertigo as a symptom in the proving. In Lippe's 
Repertory of Characteristic Symptoms 103 remedies 
are given under Vertigo, and of these more than one- 
fourth are in italics. The sub-rubrics under the 



324 THE BRAIN. 

general heading in both the Symptom Register and 
Lippe's Repertory, facilitate greatly the choice of the 
remedy. 

The peculiarity of the vertigo itself will at times 
enable us to select a curative remedy ; thus, a vertigo 
that was one-sided, so the patient asserted, was entirely 
relieved by Conium mac. 3, and the feeling that the floor 
or ground was wavering under her was cured by 
Teplitz spring water, potentized to the third or fourth. 



Tropho-Neuroses. 

Progressive Muscular Dystrophy Under this 
term are included all cases of progressive muscular 
atrophy that are not of spinal origin. 

As the affection is a "family" disease, appearing in 
several members of the same generation and in those 
of successive generations, it is considered to depend 
upon some fault in the germ, in the embryonic plan 
of the muscular system. 

Although the trouble is seen much more frequently 
in males than in females, yet the line of descent is 
usually through the female. 

There are four chief types of the affection, each 
characterized by symmetrical selection of different sets 
of muscles, and each first appearing at one definite 
period of life. Yet members of the same generation 
may exhibit the disease in different types, and transi- 
tional forms of the affection exist — all showing that 
it is, whatever the type, but one and the same dis- 
order. 

The anatomical changes found in the disease are 
limited to the muscles, the constituent fibres of which 
are hypertrophied at first, and later atrophy. In the 
latter period the atrophied fibres are seen thinned, 
with fissures and vacuoles in their interior, or in frag- 
ments with great increase of their nuclei. Connective 
tissue proliferation replaces the destroyed fibres, or 
is found between them, or fat deposits occur, both 



326 TKOPHO-NEUROSES. 

conditions at times giving the appearance of hyper- 
trophy of the part. Pseudo-hypertrophy is absent in 
most of the types of the affection. 

The chief types of the disorder are : 1, the pseudo- 
hypertrophic, beginning between the ages of four and 
nine ; 2, the infantile form, with affection of the 
shoulder girdle as well as implication of the facial 
muscles, beginning below the age of four ; 3, the 
juvenile form, affecting the muscles of the shoulder 
girdle and beginning in youth or later. 

A so-called hereditary form is like the first form, 
but without pseudo-hypertrophy ; it begins between 
the eighth and tenth years. 

Pseudo-hypertrophic paralysis begins, as stated, 
in childhood. The parents notice that the child falls 
easily, has an awkward, waddling gait, and cannot 
stand erect. This excites remark, as the child gener- 
ally has apparently well-developed or over-developed 
calves and thighs. When standing there is marked 
lordosis of the spine from weakness of the glutsei 
muscles ; at the same time the abdomen is protruded. 
The lordosis disappears on sitting and a reverse curve 
is then apparent (weakness of the erectors of the 
spine). Going up stairs is difficult without the aid 
of the arm pulling on the banister; he cannot rise 
if lying, except by getting on all fours and then 
throwing one hand quickly to grasp the thigh, follow- 
ing this action by a similar one with the other hand 
— thus climbing up the thighs (Growers) — all due to 
weakness of the glutsei muscles. 



INFANTILE TYPE OF MUSCULAR DYSTROPHY. 327 

In course of time the muscles about the shoulder 
become affected, usually without pseudo-hypertrophy, 
often with abnormal position of the scapula. Occa- 
sionally a muscle will show a real hypertrophy. The 
face is involved only exceptionally. 

There are no sensory disturbances ; the skin over 
the affected parts is often cold and of bluish mottled 
appearance. The tendon reflexes disappear when 
atrophy has advanced in the related muscles. There 
is no involvement of the bladder. 

Contractures may occur in the affected muscles, 
especially the gastrocnemii, with consequent talipes 
equinus. 

The presence of imbecility, epilepsy or other cere- 
bral disturbance must be considered as a complication. 

The infantile type of muscular dystrophy is dis- 
tinguished by wasting of the facial muscles proper, 
the masseters not being affected. The orbicularis of 
the eye and that of the mouth waste early. In con- 
sequence the eyes cannot be completely closed and 
the lips protrude somewhat as a snout. Movements 
of the lips in closing the mouth, in smiling, whistling 
and speaking are greatly impeded. 

When the other muscles of the face are affected, 
emotional expression is gone, and the face assumes a 
mask-like appearance. 

The process next extends to the muscles of the 
shoulder girdle, and still later to those of the pelvic 
girdle. The facial atrophy may precede or follow that 
of the shoulder or pelvic region. 



328 TROPHONEUROSES. 

The juvenile form of muscular dystrophy (Erb's 
form) appears first in the muscles of the shoulder 
girdle, as follows : the pectorals, trapezius, latissimus, 
serratus magnus, rhomboideus, biceps, the flexors of 
the forearm and the triceps. The sterno-cleido- 
mastoid, levator anguli scapulae and deltoid escape for 
a long time, and the forearm and hand muscles are 
but rarely involved. The wing-like position of the 
scapulae is well marked in this form. 

Later, the muscles of the pelvic girdle become af- 
fected and those of the thighs and legs, the calf muscles 
usually escaping; then the functional symptoms are 
like those seen in the pseudo-hypertrophic form. 

Pseudo- and real hypertrophy may be observed in 
single muscles. 

Types of progressive muscular dystrophy cannot at 
times be made out according to the descriptions- just 
given ; indeed, from the latter it will be seen that 
the longer the patient lives the greater the tendency 
to resemblance of cases among themselves. 

The progress of the affection is slow, yet this state- 
ment needs qualification. The earlier it appears and 
the greater the pseudo-hypertrophy, the more rapid 
will be its course. Growers maintains that it is almost 
certain that any child with pseudo-hypertrophic paraly- 
sis will not live to reach adult life. 

In the other forms the duration of the disease is 
from ten to fifty years. Its progress is rarely at a 
uniform rate ; it may cease to advance for long 
periods (24 years in one of Gowers' cases), or, after 



JUVENILE FORM OF MUSCULAR DYSTROPHY. 329 

a cessation lasting for years, it may affect a new part 
and in a very short time a third. 

The electro-irritability of the affected muscles is 
simply lessened in proportion to the amount of atrophy ; 
RD is not present. Fibrillation of the affected muscles 
is rare. 

Prognosis. There is no hope of cure, but the long 
periods of cessation of the disease that have occurred 
in many cases give some hope that the cessation may 
be permanent. 

Life is not directly threatened by the disorder, but 
when the shoulder girdle is affected so many muscles 
concerned in respiration or in expanding the chest are 
involved that imperfection in the former act and a 
falling-in of the chest walls prepare the way for pul- 
monary trouble, especially phthisis pulmonalis. Most 
cases, however, die of some intercurrent disorder. 

The diagnosis of progressive muscular dystrophy is 
not difficult in cases uncomplicated by some spinal 
disease. The beginning of the affection in the muscles 
of the shoulder or pelvic girdle with the almost abso- 
lute immunity of the hand muscles from attack, dis- 
tinguish the trouble from progressive muscular atrophy 
of spinal origin ; hypertrophy, pseudo or real, is not 
seen in the spinal affection. 

When the face is affected, as in the infantile form, 
the speech difficulty, from involvement of the orbi- 
cularis oris, may bring up the question of bulbar 
paralysis. But in the myopathy the tongue, pharynx, 
larynx and masseters are not affected. 



33° TROPHONEUROSES. 

Treatment. Since it is held that progressive mus- 
cular dystrophy is but the manifestation of a defective 
development of the germ, to attempt its cure or arrest 
by medicines would be as futile as to endeavor by the 
same means to "cure" or change any other congenital 
defect. Gowers suggests from the variations in the 
time of appearance and its mode of extension that oilier 
influences may co-operate with the congenital tendency 
in causing the myopathy. 

Muscular exercise seems to be a desideratum, for 
when it is stopped there is a quicker failure of strength 
(Gowers). In the pseudo-hypertrophic form the ability 
to stand is lost, through contraction of the calf muscles, 
before weakness causes the loss. Tenotomy is there- 
fore advised, to let down the raised heels and enable 
the patient to stand, and the operation may be repeated 
with benefit if the necessity for it again arises (Gowers). 

Of our remedies Phosphoms has been of undoubted 
service, and one case of cure (cessation of advance?) 
has been reported. In the writer's hands this drug 
in the sixth dilution (with daily applications of fara- 
dism over the affected areas) has been followed by 
undoubted improvement. 

The general health of the patient should be looked 
after; its impairment will hasten the onset or accelerate 
the advance of the disease. Hence all the symptoms 
of the case should be taken into account when selecting 
a remedy, preference being given to the great anti- 
psorics. 

Progressive Neurotic Muscular Atrophy. This 



PROGRESSIVE NEUROTIC MUSCULAR ATROPHY. 33 I 

rarely seen affection begins as a rule in the first or 
second decade of life, occasionally at a later period and 
it has been observed at birth (Goldscheider). It is a 
"family" disease, has appeared in several members of 
the same generation and has been noted in several 
successive generations. Males are attacked by it twice 
as often as females and the inheritance seems to be by 
the paternal line (Oppenheim). 

It 'begins by wasting of the peroneal muscles, next 
the common extensors of the foot and the extensor of 
the great toe and later the calf muscles. In con- 
sequence gradual development of talipes varus or 
equino-varus appears and this is characteristic of the 
disorder. After some years the muscles of the hands 
are attacked, the thenar and hypothenar eminences 
wasting, as well as the interossei, giving rise in advanced 
cases to the "claw hand". 

Both sides are affected, but not always in equal 
degree. 

The muscles of thighs and upper arms escape for 
a long time. 

Fibrillary tremor is frequently observed and the 
reaction of degeneration is present. Even in parts not 
yet attacked faradic contractility of muscles is slowed 
or even lost (Oppenheim). 

The tendon reflexes disappear in the affected parts. 
Some hypsesthesia and, at times, pain, accompany the 
wasting. 

The affection is believed to be a degenerative neuritis 
of the endings of the peripheral nerve fibres as a result 



3 3 2 NEUROSES. 

of defect in development. Whether the muscular 
involvement is secondary to the neuritis or is simply 
co-existent is not decided. 

Prognosis for cure is nil, but as the disease has at 
times shown long periods of remission, treatment may 
be of service in retarding the advance of the affection. 
No case has been reported in our literature. Treatment 
must be constitutional after study of the whole case. 

Neuroses. 

Facial spasm. The muscles of the face are in such 
constant play in emotional expression and hence re- 
spond normally with such rapidity to cortical or sub- 
cortical impulses that it is not surprising that abnormal 
habits of activity are easily acquired. A not uncom- 
mon spasm is that of the orbicularis oculi (blepharo- 
spasm) ; it is often begun by voluntary contraction of 
the muscle in the endeavor to shut out painful im- 
pressions of light during photophobic conditions, or in 
the partial closure of the lids in myopes when looking 
closely, or by frequent fits of weeping, etc. It occurs 
in paroxysms aroused by some effort with the muscle, 
by a draught of air upon the eye, bright light, etc. 
The involuntary contractions are short (clonic), rarely 
prolonged (tonic), are not accompanied by pain and 
cannot be suppressed by the will. They are generally 
unilateral, but bilateral blepharospasm is not at all 
rare. 

From a long existing blepharospasm the trouble fre- 
quently extends to the zygomatic muscles and then 



FACIAL SPASM. 333 

to the muscles levator 1. sup. et alaeque nasi in some 
cases. The spasm may extend to the frontalis above, 
or as far as the platysma below. 

Facial spasm is in most cases unilateral ; the sharp 
quick contractions may occur in rapid series for a 
greater or less period, or may come singly at relatively 
long intervals. A paroxysm may be brought on by 
mental emotion, by exertion of muscles of face or 
jaws, by exposure to cold, etc. 

The underlying cause is in most cases in the cerebral 
cortex ; even where there is some evident peripheral 
cause whose removal gives relief, we must consider 
that cause to have been an exciting one only. The 
sufferers from this trouble are always neuropathic and 
not infrequently have some other nervous disorder, 
generally hysteria or neurasthenia. 

The prognosis of the disorder is bad in neuropathic 
individuals ; when a reflex cause can be found, its re- 
moval will give great help, but will not assure a cure 
if the trouble has existed for a long period of years. 
Blepharospasm dependent on ocular troubles is more 
amenable to local treatment. 

Treatment of facial spasm by remedies is a thank- 
less task if the trouble have existed for any consider- 
able time. At the New York Ophthalmic Hospital the 
routine remedy for blepharospasm is Agaricus muse, 
any ocular trouble being first relieved. At the writer's 
hands it has never done anything to relieve either 
blepharospasm or facial spasm. He has seen Kalmia 
cure for a time facial spasm, it being indicated by 



334 NEUROSES. 

the sense of stiffness about the eye of the affected 
side. The trouble returned in a few months, but the 
remedy failed then to help. Many of our drugs have 
produced in the provings spasmodic twitching in the 
face, but the selection should be made after study 
of all the symptoms of the case. Before recourse is 
had to surgery in extreme cases, it would be well to 
try the effect of hypnotic suggestion. 

Torticollis. Wry-Neck. An extremely obstinate 
and annoying affection in which the head is turned 
upon the neck in some abnormal position by tonic 
spasm of certain neck-muscles. The muscles are the 
sterno-mastoid, trapezius, splenius and those of the 
sub-occipital region. 

The sterno-mastoid is in almost every case affected; 
the head is rotated to the opposite side, the chin 
turned slightly upward, while the head is inclined 
somewhat to the side of the overacting muscles. If 
the upper part of the trapezius of the same side be 
associated in the spasm, as it most often is, the in- 
clination of the head to the same side is considerably 
increased and the head is somewhat retracted, but the 
rotation already existing is only slightly increased. If 
the splenius of the opposite side be associated the 
rotation is much greater. Both trapezii may be in- 
volved and then there is retraction of the head; this 
is a rare form and is termed retrocollic spasm. Other 
combinations of muscles in the spasm occur with cor- 
responding changes in the character of the abnormal 
position of the head. 



TORTICOLLIS. 335 

Distant associated spasms occur, such as spasm of 
the frontales when retrocollic spasm exists, or of the 
arm or face. 

The disease most often appears in women and in 
early adult life. Its subjects are generally neurotic 
and often of neurotic heredity. It may come with- 
out any known exciting cause, but trauma, exposure 
to cold, over-use of the neck-muscles, exhausting oc- 
cupation together with mental strain are common 
causes (a daughter nursed her mother during the 
latter s illness ; the loss of sleep and the anxiety 
apparently caused an attack of wry-neck, which has 
persisted for several years). 

There is no sensory disturbance, except some pain- 
ful stiffness at the beginning. In some cases slight 
vertigo preceded the onset. The spasm begins in 
slight degree, often in one muscle only ; it ceases and 
returns, increases slowly and extends, but it may be 
months before it reaches its height and becomes 
permanent. Cases have developed fully within a few 
days. In bad cases the spasm, with its periods of 
remission, becomes permanent, with no cessation ex- 
cept during sleep. 

The muscles involved become hypertrophied after 
long continuance of the disease. 

The pathology of the disease is not known, but 
it is surmised that for associated movements of the 
muscles involved, a centre, possibly in the pons, is 
the seat of some functional change. The writer con- 
siders the affection to be primarily cortical. 



336 NEUROSES. 

Diagnosis. Congenital wry-neck is seen in chil- 
dren. It is due to injury at the time of birth or 
to intra-uterine cause. In either case there is short- 
ening of the sterno - cleido - mastoid muscle. The 
trouble does not show until the child is some 
months old, and later the shortened muscle is seen 
to be small and free from active contraction. 

Disease of the tissues of the neck or spine may 
set up, reflexly, spasm. Examination will reveal such 
cause. 

Prognosis for cure or even marked improvement 
is poor, yet undoubted cures have been effected. 
The writer recently received a letter of thanks from 
a patient who has now been free from the affection 
for more than a year. The remedies given were, 
however, prescribed for her general symptoms, and 
not merely for the spasm of the neck -muscles. 
Laclinanthes tinctoria, Belladonna, Lycopodium, Lachesis, 
Nux vomica, Bhus toxicodendron and Sulphur are 
credited with cures in homoeopathic literature. 

Habit Spasm. When in the company of a number 
of persons an observer occasionally finds his attention 
directed to some individual whose action is peculiar. 
This action may be some form of grimace (facial 
spasm), a shrug of the shoulders, a shaking of the head 
as if to settle the hat in place, or a movement as if 
to escape some annoyance from the collar, etc. The 
repetition of the movement at longer or shorter inter- 
vals shows the existence of a habit. 

Habit spasm is most frequently seen in children, 



EPILEPSY. 337 

but is by no means rare in adults. Its subjects 
are neurotic, often have some other nervous affec- 
tion, and have a neurotic heredity. 

The condition is probably of cortical origin, al- 
though its immediate cause may be reflex. Thus 
the winking spasm, or habit of winking much oftener 
than normal, may be set up by the presence of 
conjunctivitis or similar trouble. 

Treatment of habit spasm must be that of the 
whole individual. Iu children hygienic and dietetic 
measures, together with physical education, will tend 
to strengthen the weak nervous system and distract 
the attention of the patient from self. No attempts 
to control the habit by parents or teachers should 
be made. 

In the adult to improve the general health is 
about all that can be done by medicine, but the 
influence of suggestion may be effective ; suggestion 
does not require hypnosis as a necessary condition — 
it may be carried by a placebo. 

Epilepsy. 

Epilepsy is a disease whose manifestations occur 
at varying intervals, and consist of loss of con- 
sciousuess (in the ordinary sense of the word) with, 
usually, a general convulsion. 

Convulsions similar in type to those of genuine 
or idiopathic epilepsy, with loss of consciousness, 
occur in the course of cerebral affections, with ir- 
ritation of the cortical motor areas by gross lesions, 



338 NEUROSES. 

such as tumor, or as in dementia paralytica, pachy- 
meningitis, syphilis, etc. ; this condition is called 
symptomatic epilepsy. 

Reflex epilepsy is the state of recurring convul- 
sions, with loss of consciousness, the exciting cause 
being some peripheral focus of irritation. The cells 
of the individual's cortex are probably unstable, but 
not so much so as in cases of genuine epilepsy; 
removal of the peripheral exciting cause cures the 
manifestations usually. Among such causes are ir- 
ritable cicatrices, affections of the digestive tract, 
uncorrected errors of refraction, muscular anomalies 
of the eyes, hypertrophies in the posterior mires, etc. 

Jacksonian epilepsy is a symptomatic epilepsy, 
and is due to an irritative lesion affecting part of 
the motor area. The convulsive action begins in 
the related peripheral part, as a thumb, a hand or 
a foot, and in typical cases spreads to the rest of the 
side and then to the other side; it may be, however, 
limited to one part or to one side, and is not in- 
frequently followed by temporary paralysis of the part 
convulsed, and in such cases loss of consciousness is 
not to be expected. Sensory disturbances, (paresthe- 
sias, etc.,) may accompany the spasm or may be the 
only manifestation of the cortical explosive action. 

Chronic alcoholism or the habitual drinking of ab- 
sinthe sets up changes in the brain that lead to 
epileptic manifestation, due probably to grosser alter- 
ations in the tissues than those causing genuine 
epilepsy. Trauma, blows or falls upon the head, may 



EPILEPSY. 339 

cause a local meningeal or cortical lesion and eventu- 
ally cause partial epilepsy, but in some cases the 
spasms cannot be distinguished from those of idiopathic 
epilepsy. 

Lead poisoning, when long continued, is reported 
as having caused attacks not distinguishable from the 
genuine form. 

The idiopathic disease is considered to be one of 
the degenerate states. In proof of this the following 
statements are offered. Heredity: the examination will 
show a history of some recurring severe type of nervous 
disease (epilepsy, migraine, etc.,) in a parent or near 
relative, or alcoholism, or insanity, or queerness, or 
" crankiness" in parent, or near relative; the patient 
frequently bears the evidences of degeneracy. 

In the majority of cases the disease first appears 
in the second decade of life, the proportion being 
specially great about the period of puberty, a smaller 
though still considerable proportion occurring in early 
childhood in connection with the process of dentition, 
or following an attack of infectious disease, especially 
scarlatina. Cases developing after adult age are few 
and then are mostly of the symptomatic variety. 

The frequency of the attacks varies greatly, yet it 
is almost a rule that at first they are separated by 
intervals of perhaps many months, but with recurrence 
the interval lessens. In a case well established in 
point of time, the average interval is in my experience 
three or four weeks. Often the attacks are grouped, 
several coming on within a week or two, being fol- 



340 NEUROSES. 

lowed by a period of freedom for some months. Daily 
attacks are not rare, especially when of the lighter 
type. 

The attacks occur more frequently during the wak- 
ing hours than during the night-sleep; in some instances 
they happen only during the latter and are then 
classed improperly as nocturnal epilepsy. In women 
the spasms tend to appear at or just before the men- 
strual period. 

The occurrence of an attack can not infrequently 
be traced to indigestion, excesses of different kinds, 
strong mental emotion, etc. 

Premonitions of the attack are felt and in course 
of time recognized as such by the sufferer in many 
instances; they are conditions of malaise of many kinds, 
irritability, sense of fatigue, mental depression, etc., 
and may exist from a day or two to a week or two, 
before the outbreak. 

Immediately preceding the attack and properly a 
part of it, certain warnings of its oncoming are felt 
in a large proportion of the cases. 

This warning is generally some paresthesia (often 
the sensation of a breeze blowing on some part — 
hence the term aura which has been applied to all 
the forms of warning), or an indescribable sensation 
beginning in the region of the stomach and ascending 
to the head, on reaching which the attack is fully on. 

The attack begins as a sudden onset of unconscious- 
ness, the patient falling from the upright position or 
from the sitting posture to the ground, and immedi- 



EPILEPSY. 341 

ately a tonic spasm affects the whole body so that 
the individual is stiffened, the back being more or 
less arched ; the head is retracted or turned to one 
side, the eyes often deviated to the same side, the 
upper limbs more or less flexed, the lower ones ex- 
tended. In the beginning of the tonic stage the 
patient utters a cry as a result of the sudden spasm 
of respiratory and laryngeal muscles; respiratory action 
ceases, and the face, which at first is pale, becomes 
flushed and then cyanosed. This tonic stage lasts 
from a few seconds to half a minute or so, and is 
then succeeded by the stage of clonic convulsion in 
which the limbs are affected by alternating flexor and 
extensor contractions of considerable amplitude. 

The transition from the tonic to the clonic con- 
vulsion, while rapid, is not abrupt. Intermediately a 
quivering or trembling in the muscles, or twitchings 
especially in the face are seen and then the clonic 
stage begins. 

The movements have not the character of purpose, 
but the patient may be injured by the violence of 
the muscular spasms; the tongue is often bitten during 
the masseters' contractions and the accumulated saliva 
which usually appears as froth at the lips, is tinged 
red by the blood from the thus wounded tongue. 
The face is distorted and the eyeballs may be actively 
in motion ; the pupils are dilated and do not react to 
light. The body temperature is slightly raised and 
the pulse somewhat accelerated. During this stage 
the bladder is frequently evacuated and occasionally 



34 2 NEUROSES. 

fseces or semen discharged. The convulsion may 
cease only to be renewed, or may gradually lessen 
until it finally disappears. 

The clonic stage lasts a few minutes only, indeed 
the time limit of the whole attack up to the cessation 
of spasm, is of importance in diagnosis. 

The next stage is that of sleep or at times apparent 
coma with stertor. In it the patient usually does not 
respond to external impressions. Its duration is vari- 
able ; when the patient awakens, it is usually with a 
headache (that in many instances only disappears 
during the next normal sleep) and a general aching 
and tired feeling. 

The preceding description applies to the severe 
attacks {grand mat), but many cases have only mild 
attacks (petit mal) in which indeed there may be no 
motor phenomena. The lightest form of petit mal is 
a sudden stoppage of mental activity, as if in a " brown 
study ", lasting but a few moments ; at its cessation 
the patient resumes his previous occupation, takes up 
the thread of conversation, often indeed not knowing 
that anything has happened. The pale face, the fixed 
stare, the dilated pupils and the unresponsiveness to 
remarks, tell to the acute observer the true state of 
the case, while in the existence of twitch ings of the 
muscles of face, lips or tongue, of the eyelids or of 
the extremities, even an uninterested observer will 
recognize the trouble. The attack of petit mal is 
often preceded by an aura. 

In some cases the individual simply falls uncon- 



EPILEPSY. 343 

scious and remains so for a few seconds without any 
spasm, or falls asleep to all appearance and wakens 
after a short time evidently surprised. This form is 
known as narcolepsy. 

Procursive epilepsy is that form (rare) in which the 
patient is apparently seized by an impulse to run or 
walk forwards for some distance (rarely backward), 
or does some other action — all as if in a dream and 
in unconsciousness ; he may go from this state into 
an ordinary epileptic convulsion or may return to or- 
dinary consciousness. 

The loss of consciousness may be an alteration 
of the patient's consciousness of his real serf, and of 
his relations to the outside world, but in which state 
he may act as an ordinary individual and may commit 
crime. This state of altered personality is not ac- 
companied by convulsions, and when the patient 
emerges from it, he is without memory of his acts 
while in it, or there may be only a dim and 
fragmentary remembrance. This condition is known 
as the psychical equivalent of epilepsy. 

The state known as psychical equivalent of epilepsy, 
already mentioned, may come on at the close of an 
ordinary convulsive attack, in which case it is termed 
post-epileptic insanity, or it may be the only mani- 
festation of the disease. In either instance the patient 
may be apparently delirious or maniacal, or may be 
as if in a dream. The forensic importance of this 
form will be understood when it is seen that crime 
has been committed while in this state, and, that as 



344 NEUROSES. 

the consciousness of the individual is suspended dur- 
ing it, his legal responsibility is also absent ; the 
difficulty of proving the absence of ordinary conscious- 
ness is very great when the ordinary attacks of 
epilepsy have not already occurred. 

What is known as the status epilepticus is the 
occurrence of a series of convulsive attacks in rapid 
succession, indeed passing directly from one convulsion 
into another. The condition is a dangerous one, is 
attended by increase of temperature and may end fatally. 

Between the attacks, especially if the interval is 
long, the patient is sound in body and mind; in cases 
in which the attacks are many and at short intervals, 
there follows some mental deterioration, and in the 
young a weakening of the moral sense. That epilepsy 
is one curse of genius is no longer held, and the fits 
with which Napoleon, Mahomet and others of great 
fame were afflicted, are considered by Mobius to have 
been probably hysterical. 

The epileptic, at least such as suffer from the 
severe attacks, live in an atmosphere of danger. Falls 
into a fire or from a height, or before an oncoming 
vehicle or railway train, have repeatedly occurred- 
Apart from such dangers, the disease process itself 
undermines the resisting powers of the organism. 

The pathology of epilepsy is still a terra incognita. 
Changes in the brains of those who had epilepsy 
during life have been too varying to justify accept- 
ance of any one as the underlying cause, while the 
theory that certain layers of cells in the cortex are 



EPILEPSY. 345 

predominantly diseased, needs the support of more 
extended observation. It seems certain, however, that 
the cerebral cortex must be the seat of the disease. 
The diagnosis of genuine epilepsy is to be made by 
a knowledge of the symptoms mentioned, by the 
exclusion of any cause of the symptomatic form or 
of reflex spasms (eclampsia infantum). In a hys- 
terical convulsion the pupils respond to light, the 
spasm is largely made up of purposive motions, such 
as fighting, struggling, thrashing the body up and 
down on the bed, the patient often talks or screams, 
and convergent strabismus may be present, while the 
tongue is not bitten although the lower lip may be. 
The hysterical convulsion usually lasts much longer 
than an epileptic one. Sometimes a minor epileptic 
seizure passes into a hy steroid convulsion like that 
just mentioned, and the epileptic stage may be diffi- 
cult to ascertain unless the physician is present and 
examines the pupils. 

A minor attack may be mistaken for a fainting fit 
if no spasm or twitching is present. 

Nocturnal epilepsy (occurring during sleep) is almost 
always genuine epilepsy ; if the individual sleeps 
alone, the existence of the trouble may not be dis- 
covered for a long time. 

Auditory vertigo may be mistaken for epileptic ver- 
tigo, especially in severe cases, when the patient falls. 
The evidence of ear symptoms, especially tinnitus and 
deafness, will clear up the doubt; Gowers has, how- 
ever, seen the two conditions associated. 



346 NEUROSES. 

The prognosis. As regards the epileptic seizure r 
apart from the danger when it occurs in some position 
of peril, or when during it the patient's face is turned 
into a pillow or the bed-clothing, it rarely ends fatally, 
except in the status epilepticus. As regards recovery 
from the disease, the prospect is very poor. Gowers 
does not use the word cure or recovery in this con- 
nection (except in some cases in early life where after 
appearing, the fits disappear at the age of four or five). 
He considers that the only way known of curing the 
disease is by keeping the fits away long enough to 
permit the morbid tendency to subside. That the fits 
can be held in check in many cases by continued doses 
of bromide cannot be denied, but Growers considers 
that the drug should be exhibited in the same dosage 
for two years after the last fit, and during the next 
year the dosage is to be gradually diminished to 
nothing. 

Mobius holds that treatment, although of great im- 
portance, cannot cure the disease in the real sense 
of the word. Of bromide he says that it is indis- 
pensable and that so sure is its action in lessening 
the excitability of the cortex, that its use is of even 
diagnostic value. When by its use the attacks are 
not lessened they are probably hysterical. Gowers, 
on the other hand, says that it is far more common 
for bromide to have no influence in the case of petit 
mal than in the severe attacks. 

It will thus be seen that the prognostic views and 
percentages are largely affected by bromide as a factor, 



EPILEPSY. 347 

and the statistics given by Growers and others should 
be headed by a line reading " Under treatment by 
bromide." 

Nevertheless, the disease is curable only with diffi- 
culty, and homoeopathic treatment applied according 
to the method of strict individualization will show a 
far greater percentage of cures than will the bromide 
or opium treatment, or combination of both, or any 
other drug or aggregation of drugs. Homoeopathic 
statistics have not been as yet collected and analyzed, 
and undoubtedly many cases of cure of epilepsy have 
been reported by physicians of all shades of thera- 
peutic belief, which would not bear strict diagnostic 
tests. Mobius does not believe in the possibility of 
a real cure, but he is optimistic in claiming possession 
of a diagnostic drug ; Growers speaks of cessation of 
the attacks as the highest aim possible, but if we 
accept Mobius' diagnostic procedure a good many of 
Growers' cases of petit mal must have been hysterical. 

Gowers' probabilities in prognosis are as follows : 
The prospect of arrest is slightly better in males than 
in females, better if the disease begins after twenty 
than before, better the shorter the duration of the 
disease (being greatest when it has existed less than 
a year), better the longer the interval existing between 
the fits (very poor if fits occur daily), better if the 
fits occur only during the sleeping or the waking state 
than if thev occur in both, better if there is no con- 
siderable mental change, better if the attacks are all 
of the severe variety than if there are minor seizures, 



348 NEUROSES. 

and better if the attacks are preceded by an aura than 
if they occur without warning. 

Epilepsy due to organic disease, as well as the in- 
sanity following epilepsy, is hopeless of cure. 

The percentage of epileptics that become finally 
insane is given variously in different statistics; it is 
as low as 3 per cent, in some French statistics, and 
as high as 10 per cent, in some American ones. 

The treatment of epilepsy as a disease is largely 
a matter of hygiene. Mental and physical comfort 
(not enforced idleness), with some pleasant, not 
dangerous, occupation, the avoidance of mental or 
physical over-exertion, food of easy digestion, with 
moderation in the amount of meat, are to be pre- 
scribed. Alcohol is to be forbidden ; coffee and tea 
had better be proscribed. Indigestion, as shown by 
foul breath and coated tongue, is often the forerunner 
of a seizure, generally with constipation as an accom- 
paniment. 

The epileptic subject is always in personal danger 
and should not go out into a city's busy streets without 
an attendant, while the peril of unprotected platforms 
or bridges, nearness to open fireplaces, the ordinary 
full bath in the regulation tub, need only to be men- 
tioned here. Swimming (and bicycling) should be 
absolutely prohibited. 

That the homoeopathic treatment of epilepsy has 
resulted in cure is, in the writer's opinion, an un- 
doubted fact, but the number of such cures would 
have been largely increased could the treatment have 



EPILEPSY. 349 

been continued in all cases. Cases come to the 
physician, take the remedies for a few weeks or a 
few months, and then, not being wholly relieved of 
the attacks, cease attendance. The writer prefers 
not to take a case of epilepsy unless with the under- 
standing that he is to have full charge of it during 
a period of two years. Another cause of ill-success 
is the selection of remedies upon the indications 
observed during the fits, such as the color of the face, 
etc., instead of ignoring such points until a study of 
the whole patient has been made. 

Jahr found that most good was done in this disease 
by the use of Sulphur, Calcarea, Lycopodiam, Causticum, 
Cuprum, Silicea and Lachesis. Belladonna and Sepia 
have been credited with good results. Absinthium has 
been much praised for its influence when the fits are 
frequent in the 24 hours. Reports of cures, or at 
least of cessation of the fits, under the action of 
(Enanthe crocata tincture and also Solanum Carolinense 
tincture, have repeatedly appeared in the journals. 
In the writer's experience the latter has done nothing, 
the former helped in one case, reducing the number 
and severity of the attacks, but causing headache, 
which finally compelled the withdrawal of the remedy. 
In one case, Borax 3x, four times a day, caused 
marked improvement, but the patient disappeared 
after three months' treatment. Positive results seemed 
to follow the use of Bufo 3, not in one case only, 
but in several. Lachesis 30 helped a case sent to 
the writer for opinion, and kept the fits away for 



350 NEUROSES. 

several months ; a recurrence taking place, a renewal 
of the prescription was effective, but the outcome of 
the case is not known. Melilotus alba has been recom- 
mended by Dr. Bowen as a specific for all kinds of 
fits ; in the writer's hands it has not helped in epi- 
lepsy. Many other remedies have been praised by 
different observers in the treatment of epilepsy, but 
enough has been said to show that thorough study 
and sharp individualization are necessary, in order to 
make any lasting and beneficial impression upon the 
disorder. 

In cases that have been treated carefully by homoeo- 
pathic measures for two years without result, it would 
seem futile to attempt longer a cure ; and when no 
noteworthy lessening in the number of the attacks 
occurs, it would also seem to be justifiable to permit 
the use of bromides if they will keep the fits at bay 
without doing serious injury — in other words, palli- 
ative and antipathic treatment for relief, not homoeo- 
pathic for cure, is then in order. 

Migraine. 

Hemicrania. This affection is a constitutional vice 
whose manifestation is the occurrence at longer or 
shorter intervals of a peculiar headache accompanied 
in most cases by gastric disturbances and often by 
sensory irritative phenomena. 

The heredity is proven, first, by the fact that in 
many cases the parent had the same trouble or some 
other severe neurosis and, secondly, by the fact that 



MIGRAINE. 351 

parents afflicted with migraine at times transmit to 
their offspring a still worse disease, i. e., epilepsy. 

Migraine generally first appears about the period 
of puberty, but may begin in early childhood; rarely 
after the age of 30. 

In general the attack is preceded by some condition 
of malaise, drowsiness, pressure on the head, irrita- 
bility, etc. It begins, as a rule, in the morning, as 
headache located on one side and mostly about the 
eye, but it may extend across the whole frontal region 
or back to the occiput, or may involve the whole 
head. In some cases it begins in the occipital region. 

The pain itself may be dull and not interfere with 
the patient's occupation, but oftener it increases to an 
intense pressing or boring that is made almost intoler- 
able by motion or by any sensory irritation. Hence, 
the patient keeps in bed in a darkened quiet room. 

With the pain there is great weakness and nausea, 
often intense, and leading to vomiting. The vomiting 
may be so often repeated that bile is eventually 
brought up and thus the name "bilious headache" 
has come to be applied to the attack. 

The face is in the majority of cases pale and cool; 
the pulse is small ; in some cases the face is red on 
the affected side. There has been an endeavor to 
make two classes of migraine, one with pale face (due 
to spasm in the arteries), the other with redness (due 
to paralysis'), but it is now believed that the con- 
dition of the circulation in either case is a secondary 
one. 



352 NEUEOSES. 

After reaching its height the pain gradually dimin- 
ishes and the sufferer is able to sleep, awakening, as 
a rule, well. In some instances the attacks last but 
a few hours ; in others two or even three days. 

In the cases having associated sensory disturbances 
the most frequent are the visual ones. There is often 
a so-called blindness ; it is rather a darkening before 
the eyes, likened by the sufferer to a fog or mist. 
Or he sees a bright curve or irregular line or scintilla- 
tions, usually in one part of the visual field. The 
color of these appearances may vary. In one case 
the appearance was that of a sheet of some dimly 
seen material hanging at the left of the patient and 
having a broad yellow metallic band at the bottom. 
In another there was the appearance of a snowstorm 
before the eye, the flakes glittering. Often the figure 
is that of a zig-zag in some bright metallic coloring, 
to which the term fortification-spectrum has been ap- 
plied. These visual hallucinations last but a few 
minutes, as a rule, and are usually the immediate 
precursor of the pain. The clouding of vision may 
be hemianopic. Temporary aphasia has been ob- 
served also as a preliminary symptom. 

Paresthesia of one arm or one side, or even of 
both sides (face and tongue) have been noted and 
also hemiparesis. 

Migraine has been reported in which during the 
early part of the attack paralysis of one or more of 
the eyeball muscles occurred. 

Attacks of severe vertigo and episodes of mania or 



MIGRAINE. 353 

of confusional insanity, may appear instead of the 
regular headache. 

The intervals between attacks vary somewhat and 
yet the latter have a certain regularity ; they are es- 
pecially apt to occur at the time of the menses. They 
may be brought on by the use of certain articles of 
food owing to idiosyncracy of the patient. Thus the 
use of sugar has more than once been a cause, while 
whipped cream in any guise has been an exciting 
cause in one case. Possibly the time at which such 
articles act thus may have been coincident with that 
of an oncoming attack. Also a fit of anger or other 
strong emotion, or travel in a close railway car has 
precipitated an attack. 

Reflex causes such as errors of refraction, hetero- 
phoria of eye-muscles, hypertrophies and other ab- 
normalities in the rhino-pharynx, when present, may 
be actively exciting causes of attacks of hemicrania. 

The course of the disease is not much influenced 
by anything; it continues during life in many instances, 
but in a large fraction of the cases it becomes less 
assertive in the number and violence of the attacks 
between the ages of 45 and 50 or may even disappear. 
Change of climate has proven so beneficial in one 
case that a cure was supposed to have taken place ; 
but return to this country was followed by recurrence 
of the attacks. 

The characteristics of the first attack usually re- 
appear in the subsequent ones, but sometimes two 
sets of symptoms alternate in two attacks. 



354 NEUROSES. 

The pathology of migraine is a matter of surmise. 
The chief views concerning it are the vaso-motor 
theory, angio-paralysis and angio-spasm in or about 
certain nerve centres; the theory of "nerve storm" 
which may mean anything ; that of irritation of the 
fibres of the fifth nerve within the skull with sec- 
ondary affection of the vagus nuclei. None deals 
with the phenomenon of periodical recurrence. 

The treatment of migraine involves two problems ; 
first, the relief of the attack and second, that of the 
underlying general condition. 

In the former the remedies should be selected ac- 
cording to the special indications then present. The 
side affected (right or left), the quality of the pain, 
the influence of heat or cold, the position of the 
patient (lying upon the affected side or vice versa), 
in fact all the conditions of amelioration and aggrava- 
tion, should be taken into account. The special symp- 
toms introducing the attack, such as dimness or blur- 
ring of vision, colored spectra before the eyes, take 
high rank among the indications for remedies. 

Chief among the remedies proving beneficial in the 
treatment of the attack are Belladonna, Ignalia, Argen- 
tum nitricum, Iris versicolor, Stannum, Sanguinaria, 
Shigella antli. and Sepia. In any case of this distressing 
headache the selection of a remedy should not be 
made hurriedly. 

Ferrocyanide of potassium 30, in water, repeated 
every hour mitigated the severity of the pain in one 
case. Cyclamen 200, given in the same way during 



CHOREA. 355 

several attacks seems to have cured the patient, no 
return of the trouble having occurred during four 
years. Argentum nitricum 30, given during an attack 
was followed by the cessation of the trouble for two 
years. 

During the interval the patient should be examined 
for any possible exciting cause for the attacks and 
such cause should be removed either by internal 
remedies or by such measures as the correction of 
ocular defects, etc. 

The coal-toar products such as acetanilide and phe- 
nacetine have been resorted to as palliatives. They 
may be of great value in some cases, but the writer 
has seen them act promptly the first time and fail 
utterly in subsequent attacks. In one case the attack 
while partly relieved was much lengthened, and in 
another the attacks seemed to increase in frequency 
after their use. 

Chorea. 

The chorea of Sydenham, or chorea minor, is a 
rather common affection, seen mostly in those between 
the ages of five and fifteen, and in girls more than 
twice as often as in boys, while after the latter age 
the cases up to 25 years are almost always females. 

The cause of the disease is unknown, yet its asso- 
ciation with rheumatism and endocarditis has been 
so often observed that a common influence for both 
has been accepted. The proportion of cases in 
which articular rheumatism has an apparently causal 



356 NEUROSES. 

relation to the outbreak of chorea, has been estimated 
by American writers as from 15 to 25 per cent., 
but this proportion is increased when we consider 
that endocarditis may exist without any other evi- 
dence of rheumatism. It occurs relatively frequently 
during pregnancy, usually in young women and dur- 
ing the first pregnancy ; it occasionally follows one of 
the infectious diseases. 

Fright is the exciting cause in about 25 per cent, 
of the cases, and where injury is assigned as a cause 
the existence of fright cannot be excluded. In the 
majority no special exciting cause can be found; in 
some instances the trouble seems to depend ution 
intestinal or other reflex cause. 

The onset of the disorder is gradual in most cases. 
The child is noticed to be restless, or to " drop 
things " ; at school the writing becomes irregular and 
for this and the restlessness it is often unjustly 
punished. Later a hand or arm is thrown into 
sudden action, pronated or supinated, extended or 
contracted, a finger or thumb is actively moved, the 
mouth or forehead, or other part of the face twitches, 
a shoulder is jerked up, a foot or the whole leg is 
moved in some unexpected direction, etc. The 
movements are sudden and rapid, without rhythm, 
and often occur during some purposed action with 
which, indeed, they interfere. In bad cases walking 
may become difficult or impossible from such inter- 
ference, or the patient cannot help herself at table, 
etc. Speech may be rendered difficult owing to 



CHOREA. 357 

implication of the muscles of tongue and lips ; simi- 
larly, swallowing or pronation may be interfered with, 
while, when the respiratory muscles are involved, 
respiration may be spasmodic and irregular. 

The strength of the irregular muscular contrac- 
tions varies in different cases ; in some they may be 
slight and confined almost to the small muscles of 
the hand ; in others the whole body may be flung 
about. The movements cease during sleep, but sleep 
is delayed or at times even prevented by the motor 
unrest. 

In children there is often mental and emotional 
irritability, and they not rarely waken from sleep in 
fright. In young women at the height of the disease, 
delirium with hallucinations and maniacal excitement 
may appear. 

The tendon reflexes are not altered and no sensory 
disturbance occurs, except as part of a rheumatism, 
that may exist. Weakness of the limbs is often 
present. Many of the cases are anaemic, and in bad 
cases the interference with feeding and sleeping and 
the exhaustion from the almost constant activity of 
muscles lower the strength. 

Paralysis is not present, but in some cases the 
disease begins as a difficulty in using one arm, 
which difficulty becomes, later, total inability. An 
occasional muscular contraction and its increase with 
a corresponding decrease of the pseudo-paralysis, show 
the true nature of the affection. 

The average duration of chorea is between two 



358 NEUROSES. 

and three months, but not infrequently an attack will 
continue for six months or so; the writer has seen a 
case that had persisted for more than two years. 

In a considerable proportion of the cases a relapse 
occurs during the next year ; in a few instances a 
second relapse is seen, but rarely more. The re- 
lapses occur only in children and in chorea gravi- 
darum ; on the other hand, chorea in the adult may 
become permanent. 

The prognosis is good as regards life, death being 
rarely the ' result, and then generally in adults ; 
those dying, have, in most cases, the cardiac affec- 
tion so often present. 

The diagnosis of chorea is not difficult. The 
character of the movements already stated usu- 
ally suffices for the purpose ; some difficulty may 
be met in separating habit-spasm in its beginning 
from an oncoming chorea, and choreiform movements 
are seen to follow hemiplegia in the young — the his- 
tory, and rigidity of the affected side, will then 
show the true nature of the trouble. 

The pathological anatomy of chorea is unknown, 
the mortality of the disease being very small, and 
the cases coming to the autopsy table being gener- 
ally severe and complicated. The findings have not 
been constant. The generally accepted view is that 
the disease is an affection of the brain in which the 
motor cortical areas and perhaps the large basal gang- 
lia are specially involved. 

The treatment of chorea is a matter of studying 



CHOEEA. 359 

out the remedy, and often a succession of remedies 
will be required. The writer has had successes with 
Ignatia, Tarentula, Cimicifuga and Pulsatilla. In one 
case, after treatment of some weeks without result, 
a re-study of the whole individual led to the selection 
of Calcarea carl., which, in the 200th potency, cured 
promptly. He has never obtained any result from 
My gale. In allopathic hands he has seen remarkable 
results from the use of Fowler's solution, but Arseni- 
cum, in homoeopathic preparation, as low as 2x. has 
failed him ; it may be that much of the effect of 
Fowler's solution is due to the potash it contains, and 
hence that Causticum ought to be used by homoeopaths 
more frequently in this disease. Goodno and Bartlett 
use Agaricine 2x as a routine remedy, and claim bril- 
liant results from its use. Other remedies recom- 
mended by different observers are Veratrum viride. 
Cuprum aceticum. Belladonna, Ziucum and Sulphur. Gel- 
semium tincture has cured several cases. In any case, 
the selection of the remedy must be made by study 
of all the symptoms. 

The term electric chorea has been applied to three 
different affections. Henoch has described a kind of 
chorea appearing in children : its chief characteristic 
is the lightning-like rapidity of the muscular con- 
tractions, otherwise like those of ordinary chorea, and 
affecting especially the muscles of the nape and 
shoulder regions. 

Bergeron uses the term electric chorea to designate 



360 NEUROSES. 

an affection seen in young persons from 7 to 14 years 
of age, in whom the contractions are lightning-like in 
rapidity, involving groups of muscles and affecting one 
or more members. Thus, the head may be thrown 
in some one direction, the arm abducted or the fore- 
arm flexed, etc., with a certain rhythm. The con- 
tractions cease during sleep. Effort of the will to 
restrain them seems rather to increase them. The 
condition has a good prognosis, and Oppenheim con- 
siders it to be difficult to distinguish the affection from 
hysterical chorea. 

A peculiar disease, found in upper Italy, has been 
described by Dubini, under the title electric chorea. 
It may begin at any age with pain in head and back, 
to which are soon added contractions, lightning-like 
in rapidity, in one arm, one side of the face or, 
indeed, of the body, or affecting the whole body. 
Epileptiform attacks occur and may be limited to one 
side ; paralysis and atrophy are seen and the temper- 
ature may be considerably increased. After some 
weeks or months death occurs in most cases, usually 
by cardiac paralysis or by coma. Some infectious 
material is considered as the cause (Oppenheim). 

Hereditary chorea, or Huntington's chorea, is an 
affection first observed in Long Island. Cases of it 
now exist in Connecticut. It is inherited, affects both 
sexes and does not appear until about the 40th year. 
Its first manifestations are twitchings in the face ; 
later, the arms and legs are affected. Progressive 
mental change occurs until dementia supervenes. Post- 



PARALYSIS AGITANS. 361 

mortem, pachymeningitis, leptomeningitis, encephalitic 
processes, especially in the cortex of the motor areas 
and in the white matter beneath, have been found. 
The condition is incurable. 

Paralysis Agitans. 

Parkinson's disease. — The shaking palsy. This 
disease appears generally after the fiftieth year, rarely 
after seventy or before forty. 

Its characteristics are a special tremor, a peculiar 
rigidity of muscles, a typical position of the body 
and of the thumb and adjoining fingers, and definite 
alteration of the gait in walking. 

The onset of the disease is slow, the first symptom 
being some slight tremor in one hand, with or without 
a sense of weakness or stiffness. These first symp- 
toms do not continue, but reappear under the influence 
of strong emotion or fatigue. In time they become 
permanent and later extend to the lower limb of the 
same side. Thence they extend to the other arm 
and leg. The tremor is rather coarse, having four or 
five oscillations per second, and is peculiar in that it 
is present during rest and not during voluntary effort; 
it may increase somewhat at the beginning of a 
voluntary motion, and in a late stage of the disease 
may continue during the latter. It is increased after 
muscular effort and during emotion and when the 
patient is conscious of being observed. The tremor 
ceases during sleep. 

The special rigidity of muscles is a myotonia w T ith 



2,62 NEUROSES. 

more or less contracture dominating the flexor muscles 
and, in consequence, giving rise to a typical position 
of the body (when standing) and of the hand. 

The head is inclined forward, the body inclined for- 
ward, the lower limbs are bent at the knees ; the 
fingers and thumb may take the penholding position 
or may be simply in the position of rest, but in either 
case the tremor affects the fingers and thumb inde- 
pendently, causing the thumb and forefinger to move 
as if rolling pills. 

The position of the body in standing, as described, 
is such that a line from the centre of gravity falls 
in front of the feet, and consequently, in walking 
the patient would fall, did he not hasten his pace, 
which finally becomes in typical cases a run, and 
when he can go no faster he brings up against a 
door post, a wall, tree or some other object, from 
which he can make a new start. This hastening in 
his rate of progression is termed festination. 

The myotonic condition of muscles appears on 
attempting a movement. On starting to walk he may 
have to make two or three efforts to overcome it, 
and then he almost falls (propulsion) ; in some cases 
he is forced to take two or three steps backward 
before he can go forward (retropulsion). Rising from 
a sitting posture is accomplished only after repeated 
effort and by great exertion ; to turn over in bed may' 
be extremely difficult or impossible without assistance. 
Of this peculiarity the patient says that his feet are 



PARALYSIS AGITANS. 363 

heavy or are anchored to the ground, or that he feels 
as if fastened in the chair, etc. 

As the disease advances the speech becomes 
affected and the words are hurried; the voice be- 
comes thin, high, pitched and wavering. These symp- 
toms are not always present. 

The nutrition of the patient is often good, the 
face plump and of blooming aspect. In such cases 
the fullness of face obliterates its lines and it is 
without expression. 

The tendon reflexes are normal or occasionally 
exaggerated. Sensibility is not altered, but pains, 
rheumatic in character, may be present ; an over- 
powering sensation of heat torments the patient in 
some cases, and there may be excessive secretion 
of sweat. 

The mental state is not altered unless in advanced 
stages, when the persistence of the annoying symp- 
toms causes emotional irritability, with some tend- 
ency to depression. 

The disease is slowly progressive, two years or 
more elapsing before the full manifestations are 
evident. Occasionally there is rapid progress, especi- 
ally when the apparent cause is severe mental or 
physical shock. After the affection is fully estab- 
lished, in many cases no increase in the intensity 
of symptoms may be observable for a long time, 
but with advancing years the increase in the mus- 
cular rigidity and continuous tremor render the 
patient more and more helpless, until he finally 



364 NEUROSES. 

becomes bedridden. When the muscular rigidity 
becomes very great the tremor disappears. In some 
cases the rigidity appears without tremor; such 
cases are termed paralysis agitans sine agitatione, 
and are recognized by the characteristic posture, etc. 

The prognosis as regards life is good; death 
occurs from exhaustion or from some intercurrent 
disease. 

The pathology of the disease is as yet unknown ; 
effort has been made to see in the different results 
obtained from post-mortem microscopical investigation, 
evidences of early senile degeneration. 

With a hemiplegia, tremor may develop in the 
paralyzed limbs, simulating the tremor of paralysis 
agitans. The history, the increased tendon reflexes, 
the evidences of paralysis, will correct any doubts. 
Senile tremor affects chiefly the head, begins much 
later in life and is without the typical position of 
body or hands noted in paralysis agitans. 

The treatment of paralysis agitans is hopeless as 
regards cure ; homoeopathic remedies have not, in the 
writer's hands, been of any service in the affection. 
Antipathic treatment by hyoscyamia in so-called phy- 
siological doses may overpower the spasm and tremor 
and give the patient some relief. 

Tetany or Tetanilla. 

Tetany or tetanilla is a disease characterized by 
the occurrence usually intermittently, of bilateral tonic 
spasms affecting certain groups of muscles mostly in 



TETANY OR TETANILLA. 365 

the upper extremities, accompanied by pain and gen- 
erally without loss of consciousness. 

The disease has appeared epidemically in certain 
parts of Europe, as in Paris and Vienna, while it is 
almost unknown in Northwestern Germany. In this 
country it is extremely rare. 

It seems to affect the working class only and in 
v. Fraukl-Hochwart's tables one-half of the cases 
(males) were shoemakers and one-quarter tailors. In 
88 per cent, of these the disease appeared between 
the ages of 14 and 25 ; in less than 1 per cent, it 
appeared after 50. 

It occurs after infectious diseases, after complete 
extirpation of the thyroid gland, during the nursing 
period in the mother or child, in the latter in con- 
nection with intestinal disease or with rickets, and in 
association with dilatation of the stomach. 

The existence of small epidemics has led to the 
view that it is an infectious disease sui generis, but no 
special germ has as yet been found. Its relation to 
infectious fevers, to toxines or ptomaines as in the 
foregoing instances, are in line with its recorded oc- 
currence after poisoning by alcohol, ergotin, chloro- 
form, lead, phosphorus, etc. We can only say that 
a specific origin is as yet not proven. Fright and 
exposure to cold have been followed by tetany. 

The onset of the spasm is preceded, usually, by 
paresthesias or even pain in the fingers and hands and 
later a sense of stiffness. Then the interossei and 
the adductor muscles of the thumbs contract, with 



366 NEUROSES. 

the result that the fingers are flexed at the metacarpo- 
phalangeal joints and extended at the others while 
the thumb is pressed against the last phalanges of the 
first and second or second and third fingers, the hand 
thus assuming the position of the accoucheur's hand 
preparatory to its entering the uterus for the opera- 
tion of turning, or it may have the position used in 
holding a pen. In some case the fingers are flexed 
at all the joints, the thumb being thrust between the 
first and second fingers. The hand is flexed upon the 
forearm and often the forearm upon the arm. In the 
lower limb the spasm is a plantar flexion of the sole 
and toes, but the foot may be extended upon the leg 
and the leg upon the thigh. 

The trunk muscles are rarely affected; the masseters 
and the muscles of the neck may be at times con- 
tracted. The eye muscles may be involved causing 
temporary strabismus or spasmodic closure. 

The myotonic condition seen in Thomsen's disease 
has occasionally been observed in tetany, as it has 
also in hysteria, in multiple sclerosis and in muscular 
atrophy — (v. Frankl-Hochwart) . 

Certain tests of diagnostic value have been dis- 
covered. They all depend upon the existence of 
hyperexitability of motor and sensory nerves. When 
pressure is made upon the main nerve trunk of the 
affected part continued spasm of the part can be 
brought about. (Trousseau's symptom.) If a motor 
nerve (best in the face) be mechanically irritated as 
by a tap or by stroking, contraction of facial muscles 



TETANY OR TETAXILLA. 367 

follows. (Chvostek's symptom.) If a motor nerve be 
tested with the galvanic current it will be found that 
cathodal closure contraction occurs with weak currents 
while cathodal closure tetanus is easily produced and 
anodal opening tetanus in almost all cases. (Erb's 
test.) 

Hyper-irritability of the sensory nerves to both me- 
chanical and electrical stimulation is observed in many 
cases. Light pressure upon the supra-orbital nerve, 
for instance, causes an out-streaming paresthesia in 
the distribution of the nerve. With the galvanic cur- 
rent the spreading sensation that is only produced 
normally by strong currents, appears here with light 
ones. The hyper-sensitiveness is known as Hoffmann's 
symptom, but is not confined to tetany. 

The affection may last for weeks or months, or may 
be over in a few days. The individual spasm may 
continue but a few minutes, or it may be a few hours 
or days. 

Tetany has been seen in association with myxe- 
dema. 

The diagnosis is usually easy, but the possibility 
of hysteria having the same type of spasm and even of 
showing Trousseau's symptom is seen in a case reported 
by L. Minor (Neurologisches Centralblatt, 11, 1896). A 
case reported by the writer in N. A. Jour, of Hom'y, 
1888, was believed to be genuine tetany until the ap- 
plication of faradism, made because of alarming symp- 
toms, brought about complete relief of all the symp- 
toms. The subsequent course of the case is unknown 



368 NEUROSES. 

to the writer. In Minor's case there had been all the 
signs of genuine tetany, but some disappeared and the 
hysterical manifestation mentioned seemed to be due to 
suggestion. 

From tetanus the disease is differentiated by the 
intermittency of the spasm, by its beginning in the 
muscles of the hands, and by the late occurrence of 
trismus, when this occurs at all. 

Tetany without spasm has been observed ; that is 
to say, paresthesias and pain, especially in the hands, 
are experienced, and Chvostek's and Erb's symptoms 
are present. The state is termed tetanoid and may 
pass over into the spasmodic form. 

The prognosis for cure is good in most cases, except 
those following thyroidectomy or dilatation of the 
stomach. Cases following an infectious fever recover 
rapidly. 

Myotonia Congenita. 

Thomsen's disease. A rarely occurring disease and 
hereditary. In the family of Dr. Thomsen twenty 
cases have appeared in four generations (Oppenheim). 
The affection may begin in early childhood, at puberty 
or even later. 

The peculiarity of the disorder consists in the in- 
voluntary continuance of a voluntarily begun muscular 
contraction. Thus, the patient grasps the hand of 
another and then is unable to let go ; if he closes his 
eyes he is unable for a time to open them; with the 
larger muscles the tonic spasm seems to set in with 



MYOTONIA CONGENITA. 369 

the beginning of an effort, so that rising from a chair 
or starting to walk brings on a feeling of heaviness 
and restraint that lasts for some seconds. Eepetition 
of the effort, however, seems to limber up the muscles 
after some trials, and then they act in the ordinary 
way. 

The tonic state is heightened by mental excitement 
and by cold. In some cases the trouble is confined 
chiefly to the limbs, in others it may affect all the 
voluntary muscles. The muscles are unusually volu- 
minous, but their strength is less than their appearance 
would indicate. The electrical reaction of the nerves 
is not altered, but that of the muscles is increased. 
To faradism the muscles show tonic contraction, with 
continuance of the contraction after the ■ current has 
ceased ; to galvanism they show anodal closure con- 
tractions, usually with continuance after the current 
ceases. Repetition of the procedure at short intervals 
will bring about a normal reaction. With strong stabile 
currents Erb has caused rhythmical waves of contrac- 
tion in muscles, passing from cathode to anode. In 
some cases this phenomenon could not be obtained. 
In what direction the congenital fault lies, whether 
primarily in the muscular or in the nervous system, is 
as yet unknown. There is no abnormality in sen- 
sation, the reflexes, etc., but complications, such as 
epilepsy, psychical changes, etc., have been observed. 
The condition is life-long in duration, but remissions 
are said to have occurred. 

Related to, yet distinct from, Thomsen's disease, is 



37° NEUKOSES. 

paramyotonia congenita, described by Eulenburg. It 
was traced through six generations of one family, and 
in some of the cases the symptoms showed immedi- 
ately after birth. The chief symptom is the occur- 
rence of the tonic spasm, not from voluntary contrac- 
tion of muscle, but from exposure to cold, at times 
even in slight degree. The spasm lasts from a quarter 
of an hour to several hours, and after its cessation 
there follows some weakness for a time. The orbi- 
cular muscles of eyes and mouth are mostly affected, 
and the arms more than the legs. The electro-excita- 
bility of the muscles is lowered, but tetanic con- 
tractions are more easily produced by the current than 
normally. 

Growers describes ataxic paramyotonia as a union 
of persistent spasm similar to the temporary one of 
Thomsen's disease, with ataxia, weakness and anaes- 
thesia, especially in the hands. Electrical irritability 
of the muscles was unaltered. The trouble began at 
the a^e of 40, but the outcome of the case is not 
known. 

Jolly has reported recently a case similar, in all 
respects save one, to Thomsens disease. The pa- 
tient, a hard-working man, suffered repeated chillings, 
and at the age of 42 found that first his right and 
next his left hand became weak and would not obey 
him, owing to the tonic spasm that developed on 
closing them. The arms and legs became affected. 
The electrical reactions were as in Thomsen's disease, 
save that Erb's waves could not be produced. The 



HYSTEKIA. 371 

variation from the former disease was the presence 
of distinct atrophy of the muscles of the right thenar 
eminence. 

Myotonia, as a symptom, has been repeatedly seen 
in paralysis agitans, and an exquisite case of this has 
been reported by the writer (Hahnemannian Monthly, 
1895). The patient, on attempting to rise, could not; he 
felt as if he weighed a ton; on attempting to walk, his 
feet felt as if anchored to the floor; to turn over in 
bed at night was impossible, etc. 

Other and lesser myotonic symptoms have been 
seen by the writer in two hysterical cases. In one, 
the patient took hours at a meal, because she could 
not lay down her knife or change her spoon or cup 
until after many efforts. 

Jolly remarks upon the extraordinary resemblance 
between the muscular symptoms observed in poison- 
ing by veratrine and those of myotonia. 

Hysteria 

is a condition rather than a disease; it is the ex- 
pression in different ways of a faultily -planned nervous 
system, and hence it is a form of degeneracy. Janet, 
Blocq, Mobius and others term it a psychosis, the 
latter author describing it as an insanity characterized 
by a weakening of the faculty of psychological syn- 
thesis, combined with a narrowing of the field of 
consciousness. 

The consciousness of the normal individual can 
accept a number of impressions from the outer world, 



372 NEUROSES. 

the number varying according to the constitution of 
the brain and its training; but when his attention is 
strongly concentrated, he may become unconscious of 
everything except the matter having his attention. 
Such contraction of the field of consciousness is en- 
tirely normal. Abnormal, long-lasting narrowing of 
the field of consciousness is the condition of the 
hysterical, in which different sensorial impulses cor- 
rectly sent in by the peripheral organs, and properly 
carried to the cerebral cortex by the nerve fibres, 
are not registered in the final layer of cells (psycho- 
logically considered) which subserve the purpose or 
are the organs of conscious perception. Just how 
the cells are out of function is unknown, but the 
neurone theory and recent observations on the ac- 
tivities of nerve cells permit the erection of a working 
hypothesis. We have only to assume that the 
dendrites of the cells in question have retracted, to 
understand that no impulse can be transmitted to 
them from the brushy endings of fibres carrying 
sensory impulses. The eye may be entirely normal, 
the optic nerve and optic radiations functionate 
perfectly, but if the cells serving the purpose of 
conscious vision are in the condition just assumed 
to exist, the individual cannot see, and is psychically 
blind. Similarly we may explain all the forms of 
anaesthesia that are found in hysteria. 

In a somewhat analogous way, we may explain 
the paralyses of hysteria. If the large cortical cells- 
of the motor areas are themselves considered as 



HYSTERIA. 373 

under the domination of a higher layer (psycho- 
logically considered), subserving the purpose of 
conscious volition, we have only to assume the re- 
traction of the dendrites of such higher cells to 
understand how a hysterical palsy occurs. 

The normal mind, when in a state of concentra- 
ted attention to some one matter, is not conscious 
of ordinary sensorial impressions, nor at times of 
extraordinary ones. But such sensorial impressions 
are received by cortical cells, yet not transmitted to 
the higher (psychologically considered) cortical cells 
in direct relation to consciousness. Thus impressions 
are made upon the sensory areas of the cortex, yet 
below the cortical plane of consciousness ; later, when 
the attention is no longer concentrated, such im- 
pressions may be and often are, passed on to the 
plane of consciousness and become recognized as past 
experiences. 

Conversely, when consciousness is suspended as in 
the state of induced hypnotism, the lower cortical 
cells may be impressed by a command from with- 
out the subject, and both motor and sensory areas 
will respond accordingly ; the former then produce 
spasm or paralysis in a limb or other part of the 
body, the latter cause hallucinations, either positive or 
negative in some of the senses. The state of being 
thus affecting different cortical areas, and through 
them the different organs of the body, is known as 
suggestibility. In the abnormal brain such suggestion 
can arise from within, but in the plane of sub-con- 



374 NEUROSES. 

sciousness, and is termed auto-suggestion. A state 
of double personality thus is seen to exist both in 
the ordinary hypnotic state and in the hysterical. To 
attempt any explanation of this fact would lead us 
into the regions of psychological speculation. 

The logical faculty, that is the reasoning from 
premise to conclusion, is not the highest of our in- 
tellectual faculties. For, given a premise with a 
middle term, the conclusion can be made by a 
machine equally well with the brain cells. Indeed, 
the late Professor W. Stanley Jevons invented a 
l& logical machine." * 

Concerning it he says : " But when any proposi- 
tion is worked upon the keys, the machine analyses 
or digests the meaning of it and becomes charged 
with the knowledge embodied in that proposition. 
Accordingly, it is able to return as an answer any 
description of a term or class so far as furnished by 
that proposition in accordance with the Laws of 
Thought." Some brain cells, perhaps some definite 
layers, thus digest information and attendant propo- 
sitions brought into them, and finally present to con- 
sciousness results that are practically mechanical 
solutions of j^roblems, in so far as consciousness has 
not taken cognizance of the cellular activity then 
going on. In the normal brain such results must be 
presented to consciousness and the critical faculty 
being then called into play, acceptance or rejection 
of the conclusion follows. In the abnormal brain 



Vide Principles of Science. Vol. I, p. 127 



HYSTERIA. 375 

consciousness is not coupled with power of decision; 
and the conclusions are impressed, so to say, upon, 
it may be, either the motor or the sensory cells of 
the cortex. Jevons's machine acted infallibly : that is 
to say, with the material proposition presented to it ; 
so do the cortical cells. But if the information sent 
to the cortex be insufficient or false, then machine- 
like, the cells will give a truthful conclusion, yet only 
truthful according to the character and extent of the 
information received. Hence, hallucinations, negative 
or positive, being accepted as facts, mislead the 
higher intellectual powers, especially that of judg- 
ment or choice, into believing as true that which is 
essentially false. The case of the mother, given by 
Gowers, who, having struck her child, felt her arm 
and hand immediately paralyzed, can be explained. 
The swift conviction that she had done wrong and 
that she might be punished by a paralysis, was a 
sub-conscious result of the reasoning process, and im- 
pressed itself at once on the related motor cortical 
area. The process of reasoning or logical faculty 
does not require for its correctness the presence of 
consciousness ; indeed, its anatomical instruments may 
be likened to the parts of the Logical Machine. 
When in the proper condition of readiness for work, 
the machine " represents a mind endowed with 
powers of thought, but wholly devoid of knowledge." 
. . . . " But when any proposition is worked upon the 
keys, the machine analyses or digests;" " and is able 
to return as an answer any description of a term or 



376 NEUROSES. 

class so far as furnished by that proposition, in accord- 
ance with the laws of thought." The machine re- 
quires an operator to see that false knowledge be 
not presented to it, and the normal processes of 
the brain in this department have to depend upon 
consciousness as the first guard against admitting 
false information. With the field of consciousness 
greatly restricted and suggestibility greatly increased, 
the thought that the arm that struck the child 
might be paralyzed in punishment is reasoned out, 
sub-consciously, as being true, and the cells of the 
related motor area are impressed accordingly, and 
paralysis occurs. The condition then is more than 
a delusion, since it involves something more than 
a false belief, for the paralysis is there and is just 
as real to the patient as is the blindness in hysterical 
amblyopia. To place the motor phenomena of hys- 
teria in the same class as the sensory ones, the 
former might be called motor hallucinations, of nega- 
tive type when paralytic, of positive type when spas- 
modic or contractured — the former term has however 
the disadvantage of being a paradox. 

Paralysis of the Will has been held as the explanation 
of many of the symptoms of hysteria. Wliatever we 
may consider the Will to be we must admit that it is 
operative only within the field of consciousness ; hence 
when the latter is restricted or narrowed, the former 
is only active within such limits and then is only too 
assertive. 

Organs which in the normal state act without our 



HYSTERIA. 377 

conscious perception and beyond the domain of volition, 
are frequently disordered in hysteria, such disorders 
being part of the hysterical manifestation, but whether 
through direct influence from the brain or not it is 
difficult or impossible to decide. The digestive tract, 
the secretory glands, the heart, the lungs, the vaso- 
motor system and even the trophic functions, present 
symptoms that at times may be alarming. 

The mental powers of the hysterical are not changed 
by the affection, but remain great or small according 
to the original type of mental endowment ; but hysteria 
is found more ofteu among those who are intelligent 
(and frequently having the artistic temperament) than 
in those who are on a low mental plane. The char- 
acter, however, shows peculiarities. It is full of con- 
tradictions. The inability to fix attention on anything 
outside of themselves and their hallucinatory ailments, 
makes them forgetful, inattentive, distracted. Trying 
to convince them of the falseness of their sensations, 
etc., makes them feel as martyrs, that they are mis- 
understood, etc., and arouses a longing for sympathy 
which in turn leads to exaggeration on their part and 
often to intentional deception. 

Hysteria is characterized by certain permanent 
symptoms termed stigmata and, at varying intervals, 
by episodical manifestations or paroxysms. The stig- 
mata are anaesthesias, hyperesthesias, paralyses and 
contractures. 

The anaesthesia is, in the majority of cases, a hemi- 
anaesthesia and usually affects the left side of the body, 



37$ NEUKOSES. 

being limited by the mid-line. In other cases it may 
involve part of a limb or of the face. In any case its 
extent does not coincide with the distribution of sensory 
nerves and is mostly a loss of pain-sense, the tactile 
and temperature senses being only lessened, if at all 
affected. It commonly involves the mucous membranes 
within the affected area. It is a negative hallucination 
and its presence may be unsuspected by the patient 
until it is discovered by tests. It has been removed 
or even transferred in part to the other side of the 
body by the application of a magnet or of metals or 
of pieces of wood made to represent these (Charcot). 
Such removal lasts but a short time. 

Anaesthesia of the retina is a frequent manifestation 
in hysteria in connection with hemianaesthesia. It is 
most often a concentric narrowing of the visual field 
on the affected side with a lessened narrowing on the 
other. The fields for colors are lessened in unequal 
degrees, those for yellow and blue being least affected. 
In complete bilateral amaurosis, which is the extreme 
manifestation of retinal anaesthesia, tests can hardly 
be expected to succeed, but in monocular affections 
of this kind, the stereoscope has shown that the patient 
really saw but was unconscious of the fact. Loss of 
taste, smell and hearing on one side is sometimes found. 

Hyperesthesias, usually in small insular areas may 
exist within the area of anaesthesia, but generally they 
are in certain regions, chiefly under the mamma, in 
the region above Poupart's ligament (the so-called 
ovarian region), over the upper end of the sternum, 



HYSTERIA. 379 

and also over its middle. These spots are the seats 
of hypersensibility and often of painful sensations ; 
pressure upon them, especially the ovarian one, may 
cause a spasm. 

The paralyses of hysteria are hemiplegia, monoplegia, 
and paraplegia. No paralysis of an isolated muscle 
occurs and the face is but rarely, if ever, affected ; 
but contracture of the muscles of one side of the face 
may by contrast give the appearance of paralysis of 
the other. The paralyses usually occur rather sud- 
denly, after some mental or physical shock or after 
a spasm. In the hemiplegia the gait is unlike that 
of hemiplegia from organic disease ; the patient does 
not "mow the ground", the knee bends somewhat 
and the foot rarely scrapes the ground. 

Hysterical paraplegia is not an infrequent manifes- 
tation ; it is often associated with the hyperesthesia 
of " irritable spine" and thus may lead to the erroneous 
conclusion that disease of the spinal cord is present. 
It is in many instances attended by contracture. 

Inability to walk or to stand (astasia-abasia) would 
appear to be an incomplete form, since the patient can 
move the limbs at will when in the supine position. 

In relation to the paralyses, is the loss of power 
in arms or legs. Here the individual when walking 
loses the supporting power of the legs and may fall, 
or the arms act in a similar way and objects held in 
the hand are dropped. This condition is termed 
amyosthenia. 

The most common paralysis of hysteria is that 



380 NEUROSES. 

known as hysterical aphonia due to paralysis of the 
adductors of the vocal cords. The patient has no 
voice for speaking yet can cough or occasionally can 
sing, or during a dream can speak with ordinary 
voice. 

When the lips and tongue are affected — which is 
not frequent — the patient cannot even whisper and to 
this condition the term mutism is applied. 

Hysterical contracture may affect the limbs of one 
side, or one limb only or any part of it. It frequently 
appears after some injury or after a convulsive seizure 
or with hysterical hemiplegia. It develops rapidly, 
unlike the contracture in genuine organic hemiplegia, 
is more intense than the latter, while effort on the 
part of the examiner to overcome it causes increase 
of it that is readily felt. 

The arm is most often affected ; the upper half is 
adducted, the lower flexed at the elbow, the hand 
flexed at the wrist, the fingers flexed or clenched or 
at times fingers and thumb are in the pen-holding 
position. 

In the lower limb the contracture is one of extreme 
extension, the dorsum of the foot being in a line with 
the tibia, while the toes may be contracted or hyper- 
extended. In some cases the muscles become con- 
tractured under slight provocation, such as pressure, 
a slight blow, or even stroking the part. Such con- 
dition is known as the contractural diathesis. 

Tremor is frequently seen as a part of the hysteri- 
cal condition. It may be of any variety, and at times 



HYSTERIA. 381 

may show the intentional character. Ataxia, cerebel- 
lar in type, has been observed: so has athetosis. 

Other symptoms, that need only to be mentioned, 
are: Globus hystericus, or a feeling as if a ball were 
rising in the throat, or at times as if the throat were 
coustricted; vomiting, very frequent and often with- 
out accompanying nausea — the vomited matters may 
contain blood, and thus give rise to erroneous diag- 
nosis. The readiness with which faeces and urine 
can be put into the vomited mass by a hysterical 
patient, makes it necessary to watch such patients 
narrowly. 

Eructations, borborygmus, excessive flatus, meteorism 
stimulating tumor or pregnancy, are very common, 
while the latter may need examination under anaes- 
thesia for detection and cure. Constipation is com- 
mon and obstinate; anuria at times or polyuria may 
exist, and, as a rule, polyuria of almost colorless urine 
follows a hysterical attack. 

Hysterical joint is most frequent in the hip or 
knee. The skin over and about the joint is extremely 
tender, the patient not tolerating the slightest touch, 
but the extent of pain is too great and the rigidity 
when present, too extensive for a real arthritis. Some 
swelling may be present, however. Von Esmarch 
has stated that immersing the joint in warm water 
relieves the pain of a real arthritis, but aggravates 
that of the hysterical affection. 

Vaso-motor disturbances in hysteria are many, but 
most of them are seen in other conditions also. Blue 



382 NEUROSES. 

oedema, a cyanotic and cedematous swelling of the 
extremities, is remarkable for not pitting on pressure. 

Hysterical fever has been claimed to exist, but 
the possibility of deception here should be held in 
mind. On the other hand a lowering of the surface 
temperature in anaesthetic parts (especially with the 
blue oedema mentioned above) has been observed. 

Attacks of coughing, lasting for hours, and ob- 
stinate hiccough, continuing in some instances for 
days, are at times seen in the hysterical. 

Hysteria is separable into two forms, a minor one 
in which the severe convulsions do not occur and 
the permanent stigmata are not present. The emo- 
tional weakness, the hyperaesthesia of the sensory 
organs, the presence of globus or some similar sen- 
sation in the throat, the loss of self-control, the 
pains from which she can be diverted readily, the 
tender spots along the spine, the mental suffering at 
being " misunderstood," the exaggeration as to the 
severity and uniqueness of her symptoms — are some 
of the characteristics of the minor hysterical state. 
At times a hysterical chill with trembling, fits of un- 
controllable and causeless laughter, alternating with 
paroxysms of weeping, equally causeless, appear when 
her wishes and projects are opposed. 

In hysteria major the presence of the stigmata or 
some of them is found between the paroxysms, 
which may aifect the larynx, stomach or diaphragm, 
causing symptoms already mentioned or which may 
consist of convulsive attacks. 



HYSTERIA. 383 

The hysterical convulsion is brought on by some 
emotion, such as fright or auger, or from injury. 
The patient falls, yet usually without injuring her- 
self; the breathing may be ciyspuoeic, but there is 
no arrest of respiration and so no asphyxia. There 
may be some tonic contraction of the limbs or even 
opisthotonos, but commonly there are purposive 
movements of arms or legs, or of the trunk and 
head. Striking and thrashing about, beating the 
head against the floor, thrashing the trunk up and 
down on the bed, and every possible kind of volun- 
tary movement, may be carried out. Talking or 
screeching may be constant or occasional, or the 
vocal sounds of animals imitated. The eyeballs are 
at times converged, or turned upward or in some 
other direction. The pupils are dilated and are 
responsive to light, but the difficulty of examin- 
ing them is very great. The tongue is not bit- 
ten, but the lip may be, and there may be foaming 
at the mouth. The patient may at times be seen to 
observe those about her. 

As regards the length of the convulsive attack, it 
may be for a few minutes, or it may extend over 
hours. It may be cut short by holding closed the 
mouth and nostrils for twenty or thirty seconds, by 
dashing cold water on the face, or by pressure on 
the so-called ovarian region in women. 

Of the severe convulsive seizures, called grande 
Jiysterie, or also (improperly) hystero-epilepsy, it may 
be said that they are not seen in this country. 



384 NEUROSES. 

There is a preliminary stage of headache, psychical 
change, usually increased irritability, anxiety, etc., 
which lasts in some cases for several hours. Next 
appears the aura, generally the globus subjectively 
felt as starting from the ovarian region of the anaes- 
thetic side. The patient falls, and apparently loses 
consciousness, a stage of tonic spasm begins, followed 
by clonic spasm — this stage lasting two or three min- 
utes. Next comes the second stage, or stage of con- 
tortion or grandes mouvements. The patient's body 
becomes arched, resting on the soles and the top of 
the retracted head, with changes of position, by which 
the body below the shoulders is raised high up and 
then brought down, or the body is thrown from side to 
side or the limbs in active, extended movements in 
different directions, the patient striking out at times as 
if enraged, and howling, screaming, cursing, or weep- 
ing and laughing. This stage lasts a few minutes 
and passes gradually over into the next, that of emo- 
tional or theatrical manifestations. Here the patient 
assumes attitudes and facial expressions, exhibiting 
the various passions, such as fear, rage, love, hate, 
ecstasy, etc., apparently under the influence of suc- 
ceeding hallucinations, the stage lasting about a 
quarter of an hoar. The fourth stage is but the 
gradually disappearing echo of the previous one, end- 
ing at times with a fit of laughing or of weeping; it 
is termed the stage of delirium. The whole attack 
may last half an hour or less. It can be evoked, at 
least it could in Charcot's wards, by pressure on 



HYSTERIA. 385 

the ovarian region, and when begun could be stopped 
by the same procedure. 

The attack may be repeated many times. There 
is no increase of temperature, and after cessation of 
the attacks, there is often left a paralysis or a con- 
tracture. 

A part only of gr ancle liysetrie may appear. Following 
an aura, the hallucinatory stage may come on, or even 
a cataleptic condition or somnambulism, the latter in 
some instances continuing for days or weeks at a 
time. On returning to the more normal state, the 
memory of events and circumstances occurring dur- 
ing the somnambulic condition is gone, but in the 
latter the memory of previous attacks is retained. 
Thus there is a doubling of personality. 

Sleep, apparently normal, may follow a convulsive 
attack, and may continue for many days. 

The diagnosis of the ordinary hysterical convulsion 
from an epileptic seizure is not always easy. But 
usually the purposive movements, the absence of in- 
jury to the patient in falling, the unbitten tongue, 
the reaction to painful impressions (pricking the sole 
of the foot with a needle, etc.), and the relatively 
long persistence of the seizure, mark the case as 
hysteria. But it does happen that an attack of petit 
mat passes over into a hysterical one. 

Women are more subject to the "disease" than 
men, in a proportion variously stated as ten to one 
or six to one. Its first manifestation is generally in 
the years about the time of puberty, fifty per cent. 



386 NEUROSES. 

of cases beginning between the ages of ten and 
twenty. Cases have been reported as beginning as 
early as the second or third year, but in children 
paralyses and contractures are less often attended by 
anaesthesia than in the second decade of life or later. 
Many symptoms of neurasthenia are present in the 
hysterical. The affection rarely begins after the 
climacteric. 

Prognosis. The younger the patient, the better the 
prognosis of cure; children will "grow out of it," 
if the home life and school life are directed in a 
sensible way, under conditions of good hygiene, out- 
door exercise, etc., the avoidance of much petting or 
well-meant but injurious sympathy. In the third de- 
cade of life, cases of unusual type, or varying much 
from the ordinary hysteria minor, are less hopeful 
of cure. The severe forms, those following trauma, 
and such forms as occur in the adult male, are diffi- 
cult of cure; the latter do not show the change- 
ability of symptoms usually seen. 

The influence of suggestion in hysteria must be 
used as part of the "cure," and in fact many "opera- 
tions" for the relief of the trouble may be justly 
said to act by suggestion. Many ill- smelling drugs, 
such as asafcetida, valerian, etc., which have a high 
reputation among old-school physicians, may be con- 
sidered as acting in the same way. 

On the other hand, the danger of suggesting new 
symptoms to the patient by a minute examination 
for anaesthesia or hyperaesthesia, or by searching for 



NEURASTHENIA, NERVOUS IRRITABLE WEAKNESS. 387 

some internal disease, especially of the generative 
organs, should be kept in mind, and such examina- 
tions made only when evidently necessary. 

Hysteria, or a condition not to be distinguished 
from it in its minor phase, can be produced by the 
effect of physical or even emotional shock, as in the 
case ot a railroad accident. The attempt to erect a 
new class of disorders, known as traumatic neuroses, 
has not been successful, and we can speak of traumatic 
hysteria or traumatic neurasthenia, according as the 
former state is present or absent. 

The remedies useful in the treatment of the mani- 
festations of hysteria are many. As a matter of 
experience, certain ones are very frequently called 
for. Of all, the most important is Ignatia, and next 
to that in the spasmodic manifestations are Silicea, 
MoscJias, Tarentula Hispania, Belladonna, Lacliesis and 
Stramonium. In general, besides the foregoing, Lilium 
tigriniim, Sepia, Platinum, Pulsatilla, Valeriana, Nux 
moscliata, CJiamomilla, Lobelia inflata, Asafcetida and 
Sulphur have repeatedly proved serviceable. 

The hygienic measures mentioned under Neuras- 
thenia will be applicable in hysteria. 

Neurasthenia, Nervous Irritable 
Weakness, 

as the French call it, is a wide-spread affection, 
especially a result of modern civilization or perhaps 
rather of its accompanying vices and excesses. It has 
seemed to increase enormously during the past quarter 



355 NEUROSES. 

of a century and as it is often due to an inherited 
" weakness" of the nervous system, it may well be 
that the preceding two generations have by their habits 
(especially the use of tobacco and alcohol) poisoned 
their own germ-plasm so that development in the 
children is faulty and unbalanced, especially in the 
higher physiological structures. 

Other injurious causes in the ancestors than those 
just named are insufficient food (as in states of poverty), 
exhausting diseases (phthisis, cancer, etc.) and similar 
conditions that must have a profoundly injurious 
influence upon the being procreated during such states. 

The disease can be acquired by a perfectly sound 
organism as a result of insufficient food during child- 
hood or by severity or cruelty at the hands of parents 
or guardians during the same period, by the habitual 
use of alcohol, the excessive use of tobacco, by sexual 
excesses in the young, especially masturbation. Pre- 
mature sexual development and desire must be looked 
upon as a symptom of the neurotic state, but early 
indulgence only intensifies and ripens the already 
existing morbid condition. 

The hysterical individual is almost always neuras- 
thenic but the reverse is not the case, there being 
thousands of neurasthenics who have no sign of hysteria. 
But neurasthenia has its own psychosis — hypo- 
chondriasis, which is perhaps even more difficult to 
cure than hysteria. 

Neurasthenia may begin at almost any period of life. 
It may be seen in young children or even appear first 



NEURASTHENIA, NERVOUS IRRITABLE WEAKNESS. 389 

in old age, but it generally is observed in the third 
decade, and the proportion shades away in both upward 
and downward directions. 

The symptoms, although generally alike, can be 
classed under three heads : cerebral, spinal and sexual. 
In all cases, the symptoms can be described first as 
hyper-excitability, next as exhaustion. The first makes 
him hurry; he is under a sense of obligation to hurry; 
he hurries at his work and has to stop because of not 
being able to do the work at the same tempo as he 
feels urged, and so he becomes wearied or tired 
and " gives up," thereby causing annoying self-objur- 
gations. He eats in a hurry, he is overcome by the 
sense of being hurried ; it might almost be said that 
he sleeps in a hurry. 

He is fearful. Apprehensions that he will fail 
accompany him in everything that he undertakes, or 
he refuses to undertake anything lest he should fail. 
His mind is distracted ; he cannot study ; his con- 
centration is upon himself and his weakness ; one must 
be free from extraneous thoughts in order to study 
but his mind has the thought that he is studying — 
and that fills his mind and so he does not take in what 
he is reading. He directs a letter and after posting it, 
does not know that it was properly directed — and he 
worries accordingly ; he locks his front door and yet 
not knowing surely that he has done so, goes down 
again to make sure — and repeats this time after time. 
His sleep becomes broken and is not refreshing, or he 
is unable to sleep. He has headaches, most frequently 



390 NEUROSES. 

a sense of pressure on the vertex and often described 
as a tight metal cap ; similarly the sensation may be 
a tightness (or at times the sense of bursting) in the 
occipital region. Such symptoms give rise to the fear 
of some organic brain trouble. Slight dizziness with 
obscuration before the eyes or passing attacks of vertigo 
increase his fears. In many cases other morbid fears 
are present and make life a burden to him. The fear 
of going into or crossing open spaces (agoraphobia) ; 
of being in a closed room (claustrophobia) ; of being 
alone, of looking down from high places, etc. are but 
a few. To attempt any of these things, brings on an 
attack of nameless terror that simply prevents the 
continuance of the attempt and leads to refusal to leave 
home or to go to church, etc. 

Of the organs of special sense, the eye and ear 
are extremely irritable. Photophobia is often present; 
the eye muscles tire easily, the letters run together 
after reading a short time, or vague visceral sensa- 
tions are experienced (chiefly abdominal), sparks and 
stars flit before the eyes, and muscce volitantes are com- 
mon annoyances. The patient is often acutely sen- 
sitive to noise, probably from cortical irritability, as 
it is noted even when the drum-head is thickened 
and when evident lessening of hearing power is 
present. 

The general muscular power may or may not be 
lessened, but is often exhausted after relatively 
slight effort, especially in walking. Tremor is fre- 
quently observed. 



NEURASTHENIA, NERVOUS IRRITABLE WEAKNESS. 39 1 

The abdominal organs may be affected. Nervous 
dyspepsia is a common complaint among neuras- 
thenics ; the liver acts imperfectly; intestinal fer- 
mentation may be excessive, intestinal activity les- 
sened and constipation exist. The urine is, in many 
cases, concentrated, sp. gr. 1030 or over, is very high 
colored, small in quantity, and at times irritating 
when passed. 

The sensory disturbances may be tingling or prick- 
ling of hands or feet, pain at the nape of the neck, 
described as aching or at times a sense of weight, 
pains along the back, bruised feeling of the scalp, 
aching of the limbs, often worse in the morning 
when lying awake in bed. 

Cardiac symptoms may be present. Nervous pal- 
pitation, with or without acceleration of the pulse- 
rate, attacks of prae cordial anxiety and pain, simu- 
lating angina pectoris, are not infrequent manifestations. 

Vaso-motor weakness or irritability is seen in many 
cases. The feeling of increase of blood within the 
head, with redness or flushing of the face (often seen 
in women at the climacteric), with cold extremities 
and sweaty palms and soles, the easy production of red 
spots on the skin after pressure and lasting many 
minutes, are instances of the disturbance. 

The sexual organs are to the patient, in many 
cases, the centre around wmich all his nervous symp- 
toms revolve. Previous masturbation or other sexual 
excesses give rise to weakness, shown in frequent noc- 
turnal seminal emissions. These cause worry and appre- 



392 NEUROSES. 

hension of incurable disease, or of permanent impo- 
tency, or keep before the mind his self-reproaches- 
In the married, inability for the sexual act causes 
similar hypochondriacal fears. 

The frequent recurrence of nocturnal emissions in- 
tensifies the nervous state and causes great mental 
depression. When the genitals are specially weak, 
discharge of prostatic .or seminal fluid may occur 
during stool, at times containing spermatozoids. Im- 
potentia coeundi is not an uncommon complaint, but 
is probably due, in a large proportion of such cases, 
to the fear of failure. 

Sleeplessness is quite a common symptom. It is 
rarely absolute, and indeed the statements of the 
patient in this regard must be received with a good 
deal of allowance. The sleep is undoubtedly light, 
and annoying dreams add to the trials of the patient. 
A special feature related to vaso-motor aberration is 
that the patient is very drowsy while up and about, 
but on lying down becomes wide awake. 

Pains in the back, often a sense of tiredness or 
aching, unconnected with organic disease of any kind, 
are not infrequent. The most common manifesta- 
tion, however, is tenderness of the vertebral spines 
to pressure, usually in the cervical region; with this 
objective tenderness (or without it) there is a sense 
of pressure in the post-cervical region, often extend- 
ing upward into the occiput. The symptom may be 
so severe and so constant as to rob the patient of 
the power of attention to anything else. 



XEUB ASTHENIA, NERVOUS IRRITABLE WEAKNESS-. 393 

In the neurasthenic the tendon reflexes are ex- 
aggerated. In most cases the patients are fairly well 
nourished. 

The nature of the disease has been considered 
already, but the internal or external causes that keep 
it actively manifest are matters of speculation. The 
lithaemic theory is perhaps better than any other, but 
there are probably present in the system other pec- 
cant matters than uric acid. 

The prognosis of neurasthenia depends first upon 
whether the condition is inborn or acquired, next the 
age of the individual and the length of time the 
symptoms have existed, and lastly the special form 
of the dominant symptoms. The morbid fears may 
be so intense, and the mental depression so great, 
that the case really is one of mental perversion or 
insanity, and should be treated as such. When the 
sexual symptoms are the most prominent, a real cure 
cannot be expected if the trouble has been the out- 
come of years of sexual excesses. 

In most cases of neurasthenia so much improve- 
ment can be effected that we may speak of a 
relative cure; but it must be held in mind that, even 
then, influences injurious to the nervous system can 
renew the old symptoms. 

Diagnosis is chiefly to exclude organic disease of 
heart or other internal organ, or of the central ner- 
vous system. The absence of organic signs would be 
conclusive in one direction, but their presence would 



394 NEUROSES. 

not prove the non-existence of neurasthenia, since 
the latter can also be present. 

The hypochondriacal tendencies may lead to a real 
hypochondriasis, but this is to be distinguished from 
hypochondriacal paranoia. 

Hysteria and neurasthenia often co-exist, but in 
neurasthenia there are not the stigmata of the former 
disease. 

The treatment of neurasthenia is divisible into two 
kinds, hygienic and medicinal. Whether the lithsemic 
theory be correct or not, certain it is to the writer's 
mind that increased oxidation and tissue metabolism 
lie at the foundation of the successful treatment of 
neurasthenia. To effect this, hard physical labor 
(except in those whose work is such), gradually in- 
creased from a few minutes at first up to one hour a 
day; wood-chopping and sawing, rowing (when place 
and season permit) are the most efficacious kinds of 
labor. Next is bicycling, with its wonderful influence 
in developing the heart and lungs, provided the 
rider gradually inures himself to the new demands 
made upon these organs. The exercise should be 
carried out daily, with perhaps an omission of one 
day in seven; at its end a rubbing dry with a soft 
towel, and complete change of clothing and resting 
on a couch for an hour should follow. 

Lessening the amount of nitrogenous food, with 
increase of vegetables and fruits, should be en- 
joined (but most neurasthenics seem dependent on a 
plentiful meat diet); as water is a necessity to facili- 



NEURASTHENIA, NERVOUS IRRITABLE WEAKNESS. 395 

tate tissue changes and elimination of excrementitious 
products, the use of drinking water between meals, 
is an important part of the "cure." Tobacco, tea and 
coffee should be eschewed, or, if this is felt to be 
impossible, should be used only in very small 
amounts. Alcohol in any form should be avoided. 

The neurasthenic whose daily work is fatiguing 
may find the hard work prescribed above to be too 
exhausting; here the bicycle is of especial value. 
The writer has known more than one case in which 
fatigue from walking and standing (in an office or 
shop) has been entirely removed by an hour's ride 
on the wheel through the park or country. 

Cold water to the spine, by means of a hose at- 
tachment with sprinkle-nozzle, has often an invigor- 
ating effect. It may be used at such time as the 
patient finds it to act best. In the morning it will 
dissipate the achy, tired feeling that so frequently 
follows the sleep of the neurasthenic, or if used just 
before retiring it may ensure better sleep. 

Change of climate may be advantageous if busi- 
ness and other cares can be left behind; travelling, 
with its hurry and annoyances, must have a bad effect. 

The drugs used in the treatment of neurasthenia 
are, as might be supposed from the variety and dis- 
tribution of the symptoms, simply legion. Where 
the cerebral symptoms are dominant, with inability 
for mental labor, Picric acid, Calcarea carb., Kali phos., 
Nux vomica, Gelsemium, Phosphoric acid, Phosphorus 
are called for. 



396 NEUROSES. 

"When the hypochondriacal tendency is marked, 
Aurum, Kali brom. (in a potency \ Sulphur, Natrum mur. 

When insomnia is a chief symptom, Ambra, Arsen- 
icum, Cimicifuga, Coffea cruda. 

When the sexual organs are markedly affected, 
Selenium, Picric acid or its zinc salt, Phosphoric acid, 
Nux vomica, Lycopodiimi, Agnus cast, Gelsemium. 

In general, Physostigma, Berberis, China off., Plumbum, 
Silicea, Piper methyst, and other remedies have proven 
of value in the treatment of neurasthenia by the 
writer. It is advisable to take a full record of all 
the symptoms as given by the patient, and although 
a succession of remedies will probably be required to 
influence a case of the disorder, yet the proof shown 
by the record of the disappearance of certain symp- 
toms or groups of symptoms will encourage greatly 
both physician and patient. 

Traumatic Neuroses. 

The effects of injury to the individual by trauma, 
especially in conjunction with shock, either mental or 
physical, has long been known to set up a train of 
symptoms not to be accounted for by the actual phy- 
sical injury or indeed in the absence of any demon- 
strable injury. Such were often mistaken for cases 
of malingering. 

Too many cases, however, appeared where no pos- 
sible, reason for simulation was present, yet in which 
the constancy or even worsening of the symptoms 
excluded such a view. 



TRAUMATIC NEUROSES. 397 

The effort was later made to consider the symptom- 
complex as one sui generis under the title traumatic 
neurosis, Charcot meanwhile labelling such cases 
11 traumatic hysteria". 

At present the most general view is that from trauma 
of any severe kind especially when sudden and accom- 
panied by mental shock or fear (at times without such) 
there may develop symptoms of neurasthenia, hys- 
teria, hypochondriasis, melancholia, etc., at times with 
almost complete loss of emotional control and of 
mental or physical capacity for the daily occupation. 

In Germany the subject has received great attention 
because there a workman who is incapacitated for 
labor receives (partly from the State) a certain sum 
regulated according to his complete or incomplete 
incapacity, and hence every effort is made by physicians 
and jurists to expose attempts at simulation. In this 
country no such arrangements exist, and claims for 
damages against railway companies, manufacturing 
concerns, municipal corporations, etc. are made for 
injuries received, and are often defended by denying 
all liability unless objective signs of bodily injury can 
be proven to exist. 

Most observers admit that in the hysterical and 
related states there is a tendency in the patient to 
exaggerate the symptoms, and that in traumatic hys- 
tero-neurasthenia such exaggeration is often found, 
but that this is not simulation. 

The examiner of a case of nervous symptoms follow- 
ing any kind of accident should be extraordinarily 



398 NEUROSES. 

careful in making up his opinion and in fact should not 
do so until after a second or third examination at 
considerable intervals ; and he should be extremely 
reserved in expressing his opinion in general or even 
in commenting on (in the presence of the patient) 
the results brought out by his tests. Suggestibility 
exists in the hysterical condition and is not wholly 
absent from the neurasthenic ; so that the various and 
sometimes complicated methods of testing may well 
arouse the patient's attention to the highest degree 
and lead him to consider his case to be extremely 
grave. 

The symptoms vary in different cases. In some 
the mental effort becomes soon exhausted or causes 
vertigo or vertex headache (metal cap sensation very 
often); the emotional control is lessened, the patient 
cries at the least cause or is worried beyond reason 
at his inability to earn wages. Mental depression is 
frequently present. The physical powers may show 
too great exhaustibility so that a little effort fatigues 
him. 

The spinal symptoms may be predominant and the 
picture then is that of the long-known " concussion 
of the spine." Pains in the back, in the sacral region, 
in the cervico-occipital region, are the chief manifesta- 
tion. The pains are great upon movement, and the 
patient keeps as nearly motionless as possible. Para- 
lytic conditions, hysterical in character, may result, and 
may be paraplegia, hemiplegia, or monoplegia. If 
hemiplegia exist after injury to the head, it is always 



TRAUMATIC NEUROSES. 399 

on the side of the injury, thus establishing its psychi- 
cal origin. 

Anaesthesia, more often hypaesthesia, upon the side 
or part injured, or pains and paraesthesias of different 
kinds are frequently observed. 

Concentric contraction of the visual field, bilateral, 
but most on the side predominantly anaesthetic, is the 
sign of a functional neurosis, whether traumatic or 
idiopathic in origin; the contraction should be of at 
least 10 degrees to be worth considering, and the field 
for colors is more contracted than for white. Simu- 
lation is, however, not impossible here and when sus- 
pected the field should be taken at different distances. 

Certain symptoms have been found so frequently in 
conditions following accident that Rumpf considers 
them of diagnostic value. The first is a peculiar 
fibrillary tremor that spreads over the paretic muscles 
or may be more widely spread. It is seen after ex- 
posing the part to cold, after muscular effort and 
especially after applying a strong faradic current. 
The appearance produced is likened by Rumpf to 
the waving of a field of corn under the action 
of the wind. It is not always to be elicited and may 
exist in progressive muscular atrophy. 

Mannkopf s symptom is an acceleration of the heart's 
action when firm pressure is made on some painful 
spot. It is not always seen, and Rumpf has at times 
found that the pressure causes retardation and irregu- 
larity of cardiac action. In testing in this way the 
patient must breathe with his ordinary regularity; if 



400 NEUROSES. 

excited and the respiration becomes rapid, a corres- 
ponding change will occur in the heart's action. 

Vaso-motor changes are often present ; among them 
are cyanosis, which may be extensive in distribu- 
tion or in limited areas, a ready blushing of face, 
neck, even the nape or over the chest, and urticaria 
factitia. 

The vaso-motor symptoms, Mannkopf s and Rumpf's 
symptoms, the contraction of the visual fields (when 
repeatedly and properly tested), are beyond simulation 
and hence are of great importance. 

Jessen has described a form of tremor following 
trauma,* in which the lower extremities are affected by 
a convulsive tremor when motion is attempted. The 
muscles are strongly contracted, hard and prominent, 
and on cessation of effort they relax with difficulty. 
Jessen terms the condition " spastic tremor-neurosis." 
In some cases no other symptom is present, but in 
others psychical anomalies were observed ; in one case 
(Nonne) attacks of polyuria and tachycardia occurred. 

The symptoms of the traumatic neuroses may appear 
immediately after an accident or injury, or may not 
become manifest until some possibly trifling bruise or 
slight dislocation, etc., has been remedied. In other 
cases, weeks or even months may pass before the 
symptoms become evident. In some cases the, dis- 
turbances of sensation, contraction of the visual field, 
increase of the reflexes, existed unknown to the sub- 
jects, and their origin could only be ascribed (by 

* Pseudo-spastic paresis with tremor : Furstner. 



TRAUMATIC NEUROSES. 401 

means of the history) to more or less severe accidents 
through which the individuals had passed and of which 
they no longer thought. The condition may continue 
for years or permanently, without change, or symptoms 
may develop in course of time showing that in addi- 
tion to the functional disturbance of the central ner- 
vous system, organic changes have occurred there. 

Prognosis. In light cases which are general in 
extent, complete . cure may be looked for ; when there 
is much psychical change or when the neurosis is a 
local one or when the cardiac innervation has suffered, 
the outlook for cure is not bright. Oppenheim con- 
siders that the paralyses and sensory disturbances are 
far more obstinate than the corresponding symptoms 
in hysteria. 

In any case the existence of a suit for damages or 
claims for accident insurance, militate greatly against 
improvement, by the anxiety of the patient concerning 
his family's future or his own. A favorable settlement 
in such cases may be followed by marked improve- 
ment, and this was formerly taken as evidence of 
simulation or at least of intentional exaggeration ; but 
in view of the many cases in which full damages 
or insurance were allowed, no improvement followed, 
the argument falls to the ground. 

The treatment of the traumatic neuroses must be 
psychical, hygienic and medicinal. In the former, 
encouraging the patient in every way to resume his 
occupation as soon as the physical results of his injury 
have passed away. In the second, the measures already 



402 NEUROSES. 

prescribed under Neurasthenia will be found here 
equally applicable. And similarly for the third, except 
to add that Arnica given internally has at my hands 
been of great service — in the effects of shock from 
the electric current it is, I think, the main remedy. 

Occupation Neuroses. 

The repetition of muscular effort, especially when 
the smaller muscles are for long periods engaged in 
carrying out finely co-ordinated movements, or larger 
ones are compelled to make with great rapidity the same 
movement, appears to give rise to a condition of irri- 
tability in the nervous system that finally abolishes 
the ability to perform the action in question, by setting 
up spasm or pain or both. The sufferers from the 
affection are usually neurotic, the neuropathic state 
resulting to a great extent from their confined mode 
of life, or from injurious influences, such as excessive 
use of alcohol, tobacco, prolonged anxiety, debilitating 
effects of illness, etc. 

The most common manifestation is the writer's 
cramp. It appears in those who do more or less 
continuous writing, but it is believed that the inimical 
influence is rather in the mode of handling the pen 
than in the amount of the daily task. The move- 
ments of the pen, when caused by the action of the 
fingers alone, or of the fingers and hand, induce far 
greater fatigue in the small muscles of the hand than 
do the movements of the arm and forearm muscles in 
them, when writing is done in the so-called free-hand 



OCCUPATION NEUROSES. 403 

mode. Writing under conditions of insufficient space 
has in one instance caused the affection, the case being 
that of a medical student taking notes upon his knee, 
where the finger movement only could be employed. 

The trouble begins gradually, the victim finds that 
he does not write so fluently as usual; later, he is 
conscious that he is grasping the pen-holder tightly 
and this, it seems to him, causes unusual fatigue of the 
finger and thumb muscles or in those of the whole 
hand. Later still — it may be months — distinct spasm 
affects the thumb and the next two fingers and the 
movements of the pen cannot be controlled ; in some 
instances the spasm is in the extensors of the fingers 
and then the pen-holder cannot be retained in the 
position for writing. Finally, the muscles of the fore- 
arm may become involved in the spasm. 

In some cases the painful sense of fatigue increases 
in a greater ratio than does the spasm and becomes a 
distinct separate sensation of pain in hand or wrist, 
at times continuing for hours afterward, or it may 
extend up the arm. 

A rare form of the affection is the occurrence of 
tremor of the hand and arm when writing ; another is 
the so-called paralytic form, in which the muscles 
become incapable of action when the attempt is made 
to write. 

The disease is difficult of cure if it has been of 
long standing. 

Sufferers from the disorder can usually employ the 
hand at other occupations without trouble of any kind. 



404 NEUROSES. 

When the left hand is made to do the work of writings 
after the right has become useless for this purpose, 
it, too, is apt to become similarly affected. 

The seat of the disease is the central nervous sys- 
tem, but whether the motor cells in the cervical 
segments of the cord or those of the cortex are most 
affected cannot be readily decided. The pain sen- 
sation may be due to changes in the nerves of the 
arm and hand akin to those in neuralgia. Neuritis is 
said to have been observed in some cases, but such 
are not to be classed with genuine writer's cramp. 

Treatment must begin with complete cessation of 
writing; if this be impossible then the mode of wri- 
ting must be changed, so that the movements in 
writing are made from the shoulder, the hand taking 
but little, if any, part in the act; great assistance may 
be derived from using one of several mechanical de- 
vices for attaching the penholder to the writing fingers, 
thus permitting the pen to be moved across the paper 
without effort on their part. The use of gold pens, 
and of thick penholders, covered with rubber at the 
clasping point, are believed to be helpful in lessening 
the tendency to spasm. Massage, or a combination of 
massage and gymnastics, has many advocates, while 
galvanism given daily (5 — 10 ma., cathode labile 
along nerve trunks, beginning in upper arm, anode 
beside cervical spines) has been highly praised. Both 
Gowers and Oppenheim think it of doubtful value. 
The hygienic measures recommended in the treatment 
of neurasthenia should be employed here. 



AKINESIA ALGERA. 405 

The other occupation neuroses make a long list. 
Among them piano-player's, violinist's, telegrapher's, 
are those chiefly seen. The underlying conditions in 
the production of these affections are the same as in 
writer's cramp, and the principles of treatment are the 
same as in that trouble. 

Akinesia Algera. Under this term has been de- 
scribed a nervous affection, in which motion becomes 
impossible, owing to pain caused thereby. The con- 
dition is not a disease, but a symptom-complex, and 
is found in those of intensely neurotic constitution. 
The patient finally becomes completely bed-ridden, 
and is as if paralyzed. Even passive motion becomes 
painful, and moving the eyes or the jaws (as in eat- 
ing) is provocative of pain. There is a tendency to 
insanity, usually of depressed type. The disease has 
been considered incurable, bat Erb has recently re- 
ported the cure of a case that had been bed-ridden 
for nineteen years, the cure having been made by 
suggestive influence and by gradually encouraging the 
patient to use his limbs, at first but little, and then 
increasing the extent of activity, but always in spite 
of the pain. It took some two years in the process 
of cure. The medicines given were only to strengthen 
the general body functions. 

Nervous Affections depending upon Diseases of 
the Thyroid Gland. The real function of the thyroid 
gland is as yet unknown, but when the gland is re- 
moved certain symptoms appear, characteristic of the 
diseases, tetany and myxoedema. The condition fol- 



406 NEUROSES. 

lowing complete removal of the gland is one of men- 
tal dulness, sluggishness of physical actions, slow- 
ness of body growth, thickening of the skin, and, as 
final terms, marasmus and imbecility. A form of 
sporadic cretinism has been observed, due to myxoe- 
dema, and the endemic form may be the result of 
degeneration of the gland in spite of its enlarge- 
ment. 

When the thyroid gland is too active, a set ot 
symptoms follow, which are in many respects the 
opposite o± those observed in myxoedema, the ex- 
cess of secretion acting as a poison. Such symptoms 
can be produced in the healthy by administering 
thyroid extract, but, as the extract when given to a 
case of myxoedema relieves the symptoms, the ordi- 
nary idea of poison is not to be held. 

Exophthalmic Goitre. Basedow's Disease. Graves' 
Disease. The disease is seen most often in young 
persons, few cases occurring after the age of forty; 
it is far more frequent in women than in men. The 
patient is often of nervous constitution, irritable, with 
nervous disease among relatives. Several cases have 
been in the same family. 

The exciting cause most frequently assigned is 
violent mental emotion; next in frequency are physi- 
cal over-exertion and a preceding illness. 

The first symptoms are those of general malaise, 
feeling of weakness, irritability, often sleeplessness. 
The chief symptoms are acceleration of the heart's 
action, with increased pulsation in the arteries; tremor, 



EXOPHTHALMIC GOITRE. 407 

resembling that following excitement; increase in size 
of the thyroid gland; and protrusion of the eyes or 
exophthalmos. 

The symptoms just given are not always present, 
but the first and second usually are. 

The heart-beats may be as high as 180 per 
minute, and often 140 or 150; under mental or 
physical excitement the rate may increase. The pa- 
tient may suffer from palpitation of the heart, and 
be conscious of pulsation in the carotids, abdominal 
aorta, etc., while the pulsations of the carotids are 
often distinctly visible. 

The tremor is a rather rapid vibration, 8 or 10 
oscillations in the second, and with only slight varia- 
tion from muscular or mental effort. A sensation of 
general internal trembling is felt in many cases and 
is part of a general " nervousness," characterized by 
irritability, apprehensiveness, restlessness, etc. 

The increase in the size of the thyroid gland is 
not due to hypertrophy of glandular tissue, but to 
vascular engorgement, or better described as a kind 
of erection; a bruit can be both felt and heard (on 
auscultation) in the enlarged gland. Both lateral lobes 
are usually affected and generally equally; the mid- 
dle lobe is usually not much enlarged until the dis- 
ease has lasted a considerable time. One lobe only 
may be affected, and then the exophthalmos may be 
unilateral. 

Exophthalmos is, if present, bilateral as a rule. 
The eyeball does actually protrude, perhaps owing 



408 NEUROSES. 

to vascular dilatation of blood vessels within the or- 
bit and to some increase of intra-orbital fat. The 
eyelids are often more or less retracted, increasing 
the width of the palpebral fissure; at times the up- 
per lid is retracted so much that a strip of white 
sclerotic is visible above the cornea (Stell wag's symp- 
tom); in other cases the upper eyelid lags when 
the patient looks down, and for the time being the 
sclerotic is seen above the cornea (Graefe's symptom). 
The retraction of the upper eyelid may be masked 
when oedema is present, as it occasionally is. In 
some cases complete closure of the lids is impossible. 

Other symptoms considered as subordinate to those 
already given, are nevertheless of great importance. 
A very annoying one to the patient is the subjective 
sensation of heat ; it may come in flushes that seem 
to overpower with a sense of suffocation; it may be 
followed by an outbreak of sweat. The skin is com- 
monly reddened and moist, often indeed bathed in 
sweat ; hence its normal resistance to the passage of 
the galvanic current is notably lessened, frequently 
by more than one half. 

The skin in different parts of the body may be 
pigmented with chloasma-like spots ; the body often 
wastes, and the wasting, together with the discolor- 
ation of the skin, gives a cachectic appearance to the 
face — the wasting may cease, and later be replaced by 
marked increase of tissue. Insomnia is observed, 
complete or partial, in many cases. 

Often present, yet not characteristic of the dis- 



EXOPHTHALMIC GOITKE. 409 

ease are, sudden weakness of the legs, insufficiency 
of convergence of the eyes, causeless outbreaks of 
vomiting or of diarrhoea, polydipsia and polyuria. 
The knee jerks may be normal, exaggerated, or 
even wanting. 

Hysteria, or some other nervous affection, may be 
present as a complication, and dilatation and hyper- 
trophy of the heart have been noted in the course 
of the disease. 

The prognosis is fairly good for cure in cases of 
not great intensity; remissions or imperfect cures are 
most often seen. When the disease has lasted for 
years, when the heart shows distinct evidences ot 
being affected, when the mind is greatly affected, 
when exophthalmos is very marked, when the thyroid 
is very large, and when the pigmentation of the skin 
is intense and widespread, the prognosis for cure is 
not so favorable. Death comes from exhaustion, 
from heart affection, or from some intercurrent disease. 

The diagnosis is to be made by the four cardinal 
symptoms, but not all are necessarily present in the 
same case. Exophthalmos is frequently absent, and 
less frequently the enlarged thyroid. Most obser- 
vers hold that tachycardia with the tremor and some 
of the subordinate symptoms are requisite for the di- 
agnosis. The writer has seen a case of undoubted 
Basedow's disease in which the pulse was only 72, 
and Oppenheim points out that the acceleration of 
pulse rate is not necessarily continuous, that it has 
periods or times of remission. 



410 NEUKOSES. 

Eeal hypertrophy of the thyroid gland may give 
rise to many of the symptoms found in Basedow's 
disease, from pressure on the sympathetic. The dis- 
ease may last for years. 

The homoeopathic treatment of exophthalmic goitre 
has wrought many cures. The writer has seen cures 
from Lycopus, and prefers it as a routine remedy in 
the disease. A case was greatly improved under 
Sparteine sulphate, 3d dilution, and, accidentally 
learning the name of the remedy, the patient no 
longer returned, stating to another patient that he 
could get the remedy and treat himself thereafter. 

Cures have been reported by Bromine, and great 
improvement from Aurum, Calc. carb., Iodium, Ferrum, 
Natrum mur., Cactus and Belladonna. 

Galvanism, the poles being placed just behind the 
posterior borders of the sterno-mastoid muscles and 
an inch above the clavicle, is always employed by the 
writer. The application should be once a day, the 
current strength from 3 to 5 m-a, the length of each 
sitting from 5 to 10 minutes. In most cases the 
pulse rate falls from 10 to 20 beats, and if the fall 
is nearing 20, the current should be lessened in 
strength. The current strength should be gradually 
increased from zero, and at the end of the sitting 
should be gradually decreased to zero before remov- 
ing the electrodes. 



INDEX 



Abscess of the brain, 277 
Acromegaly, 315 
Acroparesthesia, 84 
Acute ascending spinal paralysis, 160 
Alexia, word-blindness, 254 
Allocheiria, defiaition of, 20 
Amyotrophic lateral sclerosis, 131 
Anaemia of the brain, 262 
Anaesthesia, definition of, 17 
Analgesia, definition of, 18 
Anarthria, 259 
Anatomy of nerve fibre, 39 
Aneurism, intra-cranial, 305 
Anosmia, 178 

Aphasia, auditory or sensory, 254 
" motor, 253 
" optical, 254 
Apoplexy, cerebral haemorrhage, 280 
" from vascular occlusion, 

acute encephalomalacia, 
288 
Apraxia, 259 
Ataxia, cerebellar, 20 
" definition of, 19 
" hereditary, Friedreich's dis- 
ease, 151 
" in peripheral neuritis, 20 
" spinal, 20 
Ataxic paraplegia, 149 
Atrophy, progressive neurotic muscular, 
330 
" spinal progressive muscular, 
129 
Auditory, sensory, aphasia, 254 

Basedow's disease, 405 

Bell's palsy, peripheral facial paralysis, 

209 
Beri-beri, 56 
The Brain, 226 
" " axis, 226 



Brain, abscess of, 277 

" anaemia of, 262 

" hyperaemia of, 263 
Brain syphilis, 306 

'*' tumor, 295 
Bulbar paralysis, acute apoplectic, 239 

" " asthenic, 241 

Caisson disease, Diver's paralysis, 161 

Cephalalgia, headache, 319 

Central nervous system, 243 

The Cerebellum, 317 

Cerebral cortex and cortical areas, 247 

" haemorrhage, apoplexy, 2b'0 

" infantile paralyses, spastic 
infantile paraplegia, 308 

" meningitis, 265 
Cerebro-spinal, epidemic, meningitis, 

272 
Cervico-brachial neuralgia, 74 
Cervico-occipital neuralgia, 74 
Chorea, 355 

electric, 359 

" hereditary, Huntington's, 360 
Coccygodynia, SO 
Compression myelitis, 116 
Contracture, test for, 24 
Cranial nerves, 144 

Degeneration of nerve, 32, 39 
Diseases of central nervous system, 243 

" of the spinal cord, 101 
Diver's paralysis, Caisson disease. 161 
Dysarthria, 259 

Dystrophy, progressive muscular, 325 
" " infantile type, 

327 
" " juvenile form, 

328 

Eighth cranial nerve, 213 
Electro-diagnosis, 27 



4H 



INDEX. 



Eleventh nerve, spinal accessory, 221 
Encephalomalacia, acute, 288 
Epidemic cerebro-spinal meningitis, 

272 
Epilepsy, 337 

" Jacksonian, 338 

" nocturnal, 345 

" procursive, 343 
Epileptiform neuralgia, 72 
Erb's paralysis, 49 
Erythromelalgia, 83 
Examination, the, 17 
Exophthalmic goitre, 405 



Facial, or seventh nerve, 208 

" spasm, 332 
Festination, 362 
Fifth nerve, trigeminus, 204 
Fourth cranial nerve, 189 
Friedreich's disease, Hereditary ataxia, 



151 



Glosso-labio-pharyngeal paralysis, pro- 
gressive bulbar paralysis, 237 
Glossopharyngeal, or ninth nerve, 219 



Habit spasm, 336 

Haemorrhage, spinal, 103 

Headache, cephalalgia, 319 

Hemianopsia, 183 

Hemiatrophy, progressive facial, 207 

Hemicrania, 350 

Hereditary ataxia, Friedreich's disease, 

151 
Hydrocephalus, chronic, 275 
" internal, 271 

Hydromyelia, 171 
Hypalgesia, definition of, 18 
Hyperemia of the brain, 263 
Hyperesthesia, definition of, 18 
Hyperosmia, 178 

Hypoglossal, or twelfth nerve, 224 
Hysteria, 371 

" major, 382 

" minor, 382 

" paralyses of, 379 
Hystero-epilepsy, 383 
Huntington's chorea, 360 



Intercostal neuralgia, 74 
Interstitial neuritis, 42 
Intra-cranial aneurism, 305 
Irritable retina, 188 

"Kak-ke," 55 

Leptomeningitis, 267 

spinalis, 107 
Locomotor ataxia, tabes dorsalis, 134 
Lumbo-abdominal neuralgia, 77 

Mastodynia, 76 
Meniere's disease, 217 
Meningitis, cerebral, 265 
" chronic, 271 

epidemic, cerebro-spinal, 
272 
Meningitis, spinal, 105 

" tubercular, 269 

Migraine, 350 
Motor aphasia, 253 

" path, primary degeneration of, 

127 
" points, 33 
Morton's or metatarsal neuralgia, 83 
Morvan's disease, 170 
Multiple neuritis, 55 

" sclerosis, disseminated or in- 
sular, 156 
Muscles supplied by spinal nerves, list 

of, 46 52 
Myelitis, 111 

" cervical, 113 
lumbar, 113 
" compression, 116 
Myotonia congenita, 368 

Neuralgia, 68 

" cervico-brachial, 74 

" cervico-occipital, 74 

" epileptiform, 72 

of fifth nerve, 71 
'* idiopathic, 68 

" intercostal, 75 

" lumbo-abdominal, 77 

" mammalis, 76 

" Morton's metatarsal, 83 

Neuralgias, reflex, 68 

" symptomatic, 69 



INDEX. 



415 



Neurasthenia, 387 
Neuroses, traumatic, 396 
Nervous irritable weakness, 387 
Neuritis, 42 

" interstitial, 42 
" multiple, 55 
" parenchymatous, 43 
Neuro-retinitis, 186 
Neuroses, 332 
Nerves, peripheral, 39 
42 
Ninth or glossopharyngeal nerve, 219 
Non-Systemic Diseases of Spinal Cord, 

156 
Nuclear ophthalmoplegia, 199 

" " progressive, 

200 



The Ophthalmoplegias, 196 
Ophthalmoplegia nuclear, 199 

" progressive nuclear, 

200 
Optical aphasia, 254 
Optic nerve, 179 

" neuritis (papillitis), 185 



Pachymeningitis cervical is hypertro- 
phica, 106 

Pachymeningitis, external, 266 
" internal, 266 

" spinalis externa, 105 

Papillitis (optic neuritis), 185 

Paresthesias, definition of, 22 

Paralysis, acute ascending spinal, 160 
" agitans, 361 

" with atrophy, tests for, 24 
" Brown-Se^quard's, 165 
" bulbar asthenic, 241 
" cerebral infantile, 308 

Erb's, 49 
" glosso-labia-pharyngeal, 237 
" of hysteria, 379 
" progressive bulbar, 237 
" pseudo-bulbar, 239 
" pseudohypertrophic, 326 
" recurrent oculo-motor, 202 

Paramyotonia congenita, 370 

Paraphasia, 255 



Paraplegia, ataxic, 149 

" spastic infantile, 308 

spastic, spastic spinal pa- 
ralysis, 153 
Palsy, shaking, 361 
Parenchymatous neuritis, 43 
Parosmia, 179 
Parkinson's disease, 361 
Peripheral facial paralysis, Bell's palsy, 
209 
" nerves, 39 

Primary degeneration of motor path, 

127 
Progressive bulbar paralysis, glosso- 
labio- pharyngeal par- 
alysis, 237 
" facial hemiatrophy, 207 

muscular dystrophy, 325 
neurotic muscular atro- 
phy, 330 
nuclear ophthalmoplegia, 
200 
Prosopalgia, 70 

Polio-encephalitis superior acuta, 199 
Poliomyelitis anterior acuta, 122 
Pseudo-bulbar paralysis, 239 
Pseudo-hypertrophic paralysis, 326 
Pupil, 192 
Pupillary reflex, 182 

Reaction of degeneration, 32, 37 
Recurrent (or periodical) oculo-motor 

paralysis, 202 
Reflexes, 95 

Sciatica, 77 

Sclerosis, multiple (disseminated or 

insular), 156 
Sensory, auditory, aphasia, 254 
Seventh or facial nerve, 208 
Sixth or abducens nerve, 190 
Spasm, facial, 332 
habit, 336 
Spastic paraplegia, spastic spinal par- 
alysis, 153 
11 spinal paralysis, spastic par- 
aplegia, 153 
Special senses, tests for, 25 
Spinal-accessory, eleventh nerve, 221 



416 



INDEX. 



Spinal cord, 87 

" " system diseases of, 122 
" " syphilis of the, 114 
" " tumors of, 165 
Spinal haemorrhage, 103 
" irritation, 173 
" meningitis, 105 
" " chronic, 110 

" nerves, list of muscles supplied 

by, 46—52 
" progressive muscular atrophy, 
129 
Status epilepticus, 344 
Stigmata of hysteria, 377 
Syphilis, Brain, 306 

of the Spinal Cord, 114 
Syringomyelia, 168 

System Diseases of the Spinal Cord, 
122 

Tabes dorsalis, (locomotor ataxia), 134 

Tenth nerve, vagus, 220 

Tests for anaesthesia, 20, 21 
" pain sense, 20, 21 
" temperature sense, 20, 21 



Tetanilla, 364 
Tetany, 364 

Thermanaesthesia, definition of, 18 
Third cranial nerve, 189 
Thomsen's disease, 368 
Thyroid gland, influence of, 405 
Tic Douloureux, 70 
Traumatic neuroses, 396 
Tremor, definition of, 23 
Trigeminal neuralgia, 70 
Trigeminus, or fifth nerve, 204 
Tropho-neuroses, 325 
Torticollis, wry-neck, 334 
Tubercular meningitis, 269 
Tumor, Brain, 295 
Tumors of Spinal Cord, 165 
Twelfth nerve, hypoglossal, 224 

Vagus, or tenth nerve, 220 

Vascular occlusion, apoplexy from, 288 

Vertigo, 322 

Word-blindness, alexia, 254 
Wry-neck, torticollis, 334 



CATALOGUE 



OF 



M EDICAL R OOKS--- 



PUBLISHED BY 



BOERICKE, RUNYON & ERNESTY, 



497 FIFTH AVENUE, 



NEW YORK, 



Any book in this Catalogue will be sent mail or express at advertised price, 

or they can be had at any Homoeopathic Pharmacy in 

this country or in England. 



REMITTANCES SHOULD BE MADE BY CHECK, BANK DRAFT, 
P. O. MONEY ORDER, OR REGISTERED LETTER. 



A MANUAL OF GENITOURINARY AND VENEREAL DIS- 
EASES, by Bukk G. Carleton, M. D. Genito-Urinary Surgeon and 
Specialist to the Metropolitan Hospital, Blackwells Island, Department of 
Public Charities of New York City and the Metropolitan Hospital Polyclinic, 
etc., etc. 315 pages. Cloth, $3.00 net; by mail, $3.20. Half morocco, 
$4.00 net; by mail, $4.20. 

From The North American Journal of Homoeopathy. " It covers the field very com- 
pletely and gives the latest and most reliable facts concerning Genito-Urinary Diseases. 
In few of our works upon the ' Specialties ' are there to be found so many pages 
devoted to the homoeopathic indications of the various drags most frequently of use. 
We predict for the book a wide sale, as it will prove of great value to the general 
practitioner." 

From The Halinemaimiail Monthly. "A work giving the best medical and surgical 
thought and teaching on the subject in the most concise and comprehensive manner 
possible, coupled with thoroughly practical information in regard to the homoeopathic 
treatment of this class of cases. The book is a model of excellence of the book- 
maker's art; the paper and binding cannot be improved upon, and the typographical 
work is second to none." 

From The American Homoeopatllist. " It deserves to be well read and as carefully 
studied. It lacks in naught. Any one chapter would be worth the price of the book 
itself. The indications for the diseases treated are excellent, and its materia medica 
is beyond criticism for its thoroughness and faithfulness of prescription according to 
the masters of the profession. Altogether the work is a desirable one for every prac- 
titioner and ought to find its way into the college room," etc. 

From Kent B. Waite, M. D. ? Prof. Genito-Urinary Diseases and Operative Surgery, 
Cleveland University of Medicine and Surgery. " A careful examination shows it to be 
the work I have long sought. It will be adopted as the text book in that department in 
the University." 

From Medical Century. " The new book is a concise treatise on the subject and is up to 
date. It is the only book in the homoeopathic school of which this can be said. The 
authors have done credit to themselves and homoeopathy by writing the work. The 
publishers have done their work well, typographically it is remarkably free from error 
and the binding is neat," etc. 

From Medical Record. "This very compact well written book gives a very clear picture 
of the clinical phenomena noticed in connection with the different features. The sur- 
gical procedures and manipulations are up to date, and all the essential surgical 
appliances and methods are given in sufficient detail," etc. 

From The Chironian. "The treatment, outside of the medicinal, is a recapitulation of the 
author's very successful experience. The chapter devoted to the treatment of gonor- 
rhoea is especially to be commended. Acute cystitis is treated briefly, but to the point; 



MEDICAL BOOKS PUBLISHED BY 

and the treatment of chronic cystitis is excellent. The article on stone covers the 
subject admirably. Purely functional diseases which in the ordinary text-book are 
simply mentioned, are here taken up individually and in a manner which cannot be mis- 
understood. The article on Syphilis is exceptionally good; eighty-three pages are 
devoted to aetiology, symptoms, cutaneous lesions, treatment," etc. > 

From The Homoeopathic Eye, Ear and Throat Journal. ''This work covers a field 
hitherto unfilled in homoeopathic literature. Its thirty-nine chapters are an able expo- 
sition of the subject from all standpoints, while the special therapy of the various 
diseases is very complete and valuable. Dr. Carleton, who has had an extended 
experience in this special line, has presented a timely book. It also marks the appear- 
ance of the well-knows firm of Boericke, Runyon and Ernesty as publishers of 
homoeopathic works. They are to be congratulated upon the excellent appearance of 
their first venture, which is typographically all that could be desired, and an admirable 
exposition of the printer's art." 

From Win. B. Tan Lennep, A. M., M. D., Prof, of Surgery, Hahnemann Medical 
College of Philadelphia, Pa. " Concise, comprehensive and up to date." 

From W. A. Dewey, M. D., late Prof of Materia Medica, Hahnemann Hospital College 
of San Francisco, Cal. " I am much pleased with the work ; it is the latest and best 
on the subject in the Homoeopathic School ; a special feature is the excellent arrange- 
ment of the Homoeopathic Remedies, and the careful indications therefor." 

From Nathaniel Robinson, M. D., Pres. Kings County, N. Y., Homosopalhic Medical 
Society. "Avery flattering triumph both for author and publishers; it should be in 
the library of every Homoeopathic physician and surgeon. It is clear, precise, and 
remarkably well up to date, both medically and surgically. There is nothing in 
Homoeopathic literature that can compare with it." 

From E. Guernsey, M. D., Pres. Medical Boards of the Metropolitan Hospital and Hahne- 
mann Hospital of N. Y. " A model of condensed thought and practical information." 

DISEASES OF THE EYE. By N. L. MacBride, M. D., O. et A. 
Chir. Dean of the College of the New York Ophthalmic Hospital; Professor 
of Ophthalmology in the College of the New York Ophthalmic Hospital, 
etc., etc. Illustrated. 310 pages. Cloth, $3.00 net; by mail $3.20. Half 
morocco, $4.00 net; by mail $4.22. 

From The Medical Century. "There are chapters devoted to the ophthalmic diseases, 
the diagnosis and correction of anomalies of refraction, operations on the eye and other 
important topics not heretofore published in any work on this subject by a homoeopathic 
author. Throughout the text of the book the indication's for the use of the homoeopathic 
remedies are tersely given and in most instances the potency is also mentioned. The 
author has in this handy volume about all that is necessary for the busy doctor to know 
of eye diseases in order to treat them with satisfaction and success." 

From The Homoeopathic Eye, Ear and Throat Journal. "This work is a model of 
brevity from the preface to the end, and bears the impress of the author's personality 
throughout. Within a reasonable compass is given a concise description of the diseases 
of the eye, optics, errors of refraction, etc. The remedies mentioned in the treatment 



are those most frequently used by the author, and the potency he has found most 
efficacious is expressed. In giving the pathology the latest German authorities have 
been followed. The chapter on the "Use of the Ophthalmoscope" is excellently 
adapted to teach students and general practitioners the art of using this excellent aid in 
diagnosis." 

From The Medical Era. "An examination of the book makes clear the fact that the author 
has succeeded most admirably in his design. It is eminently a practical work for the 
general practitioner, and gives instructions by which he may deal with all cases that 
arise in his practice that must not of necessity go to a specialist. The descriptions of 
disease are clear, and the instructions for treatment are plain and practical. For the 
general practitioner it is the best book on the eye and its diseases that we have seen. 
We wish to congratulate the publishers of Dr. MacBride's work on the very handsome 
book that they have made; it is on a fine quality of paper, type is large and clear, and 
the binding handsome and substantial. We earnestly commend the work to the student 
and the practitioner.'" 

From The North American Journal of Homoeopathy. "The aim of the author has 
been to set forth in as concise and useful a manner as possible the results of his long 
experience. While the illustrations are not numerous those that are used, both of the 
eye itself and of the instruments employed, convey much useful information to the 
general practitioner. In mentioning the remedies found to be curative the potency is 
often given, which is something contrary to the usual custom. Many important subjects 
are treated, among them being " The Art of Using the Ophthalmoscope," " The Diag- 
nosis and Correction of Anomalies of Refraction," " Operations," etc." 

From Dr. C. M. Thomas, Prof. Ophthalmology Hahnemann Medical College, Philadelphia, 
Pa. "Dr. MacBride's book is much appreciated and you will find it among those 
recommended to the students in the college announcement." 

A COMPEND OF THE PRINCIPLES OF HOMCEOPATHY 
AS TAUGHT BY HAHNEMANN, AND VERIFIED BY A CENT- 
URY OF CLINICAL APPLICATION. By William Boericke, M. D. 
Professor of Materia Medica in Hahnemann College of San Francisco, Cal., 
etc., etc. 1 60 pages. $1.50 net; mailed, postpaid, on receipt of price. 

From North American Journal of Homoeopathy. "This book covers concisely the 
whole field of Homoeopathy, with many references to its literature for its further 
systematic study both as a science and as a practical art. — It is just what it was intended 
to be — an intelligent elucidation of the salient points so often metaphorically treated by 
Hahnemann." 

From The Chironian. "To those who wish to understand, and especially to those who 
are desirous of defending the principles of our school, the book is well worth perusal.'' 

From The American Homoeopathist. "The book is divided in thirteen chapters and 
an appendix. Taking them seriatim the titles are the following: The Therapeutic 
Field; Principles of Pharmacology ; The Homoeopathic Materia Medica; Drug Proving; 
Interpretation of Drug Pathogenesis ; Drug Relationship ; The Application of Homoeo- 
pathy; The Simillimum ; The Second Prescription ; Hahnemann's Nosology ; Posology; 
The Preparation of Homoeopathic Medicines; Hahnemann's Philosophy; Appendix. 



MEDICAL BOOKS PUBLISHED BY 

A ' Compend of the Principles of Homoeopathy ' should be in the hands of every 
honest homoeopath ; it is not a large book, it is not a costly book: but it is a book that 
talks out in meeting and is filled with homoeopathic data collected from the original 
papyrus and put into readable shape. All hail to the Compend." 

THERAPEUTICS OF THE EYE. By Dr. Charles C. Boyle, 
M. D., O. et A. Chir. Surgeon to the New York Ophthalmic Hospital; 
Professor of Ophthalmic and Aural Therapeutics in the College of the New- 
York Ophthalmic Hospital, etc., etc. 404 pages. Cloth, $3.50 net; by 
mail $3.72. Half morocco, $4.50 net; by mail $4.72. — A reference work, 
divided for convenience for consultation into three parts: Part I. Remedies 
alphabetically arranged with the therapeutics relating to eye symptoms. 
Part II. Affections of the eye, under which are given the different remedies 
with their applied therapeutics. Part III. A repertorial index, alphabetically 
arranged. 

From Dr. Timothy F. Allen, A. M. ? L. L. D. ? Prof. Mat. Med. and Therapeutics N. Y. 
Homceo. Med. College. " 'The Therapeutics of the Eye,' by Boyle, is a step in the 
right direction; namely, an examination of our Materia Medica and its convenient 
presentation for use in diseases of the eye by a competent specialist, — when every 
organ shall have been studied by specialists after this fashion, their work tested and the 
results given to us, homoeopathic therapeutics will be more readily and successfully 
applied." 

From Dr. Mai'till Deschere, Prof. Pcediatry N. Y. Homceo. Med. College. "Dr. Boyle's 
work on Therapeutics of the Eyes will be of invaluable service, not only to the specialist, 
but to every homoeopathic practitioner. It abounds in reliable indications." 

From Dr. F. H. Boynton, Prof, of Ophthalmology, N. Y. Med. College; N. Y. Ophthalmic 
Hospital College, etc. "Prof. Boyle's 'Therapeulics of the Eye' is an admirable com- 
pilation of verified symptoms, the major portions of which have proved curative in the 
experience of the author and his associates, the surgeons of the N. Y. Ophthalmic 
Hospital. The arrangement under anatomical heads and repertorial index will be 
useful to the careful homoeopathic prescriber in finding the indicated remedy. The 
section on ' pains in the eyes and head ' will be of great value not only to the ophthal- 
mologist, but as well to the general practitioner. I gladly welcome the book and shall 
recommend it to my students." 

DISEASES OF THE KIDNEYS AND URETERS WITH 
THEIR HOMCEOPATHIC TREATMENT. By Bukk G. Carleton, 
M. D. Genito-Urinary Surgeon and Specialist to the Metropolitan Hospital, 
Blackwells Island, Department of Public Charities of New York City and the 
Metropolitan Polyclinic, etc , etc. Illustrated. 253 pages. Cloth, $2.75 
net; by mail $2.91. — A companion volume to a Carleton's Genito-Urinary 
and Venereal Diseases" thus completing the subject of the Uropoietic Diseases. 



From The American Homoeopathic!. "Dr. Carleton gives the profession a valuable 
book and upon an exceedingly interesting subject. — He handles his subject in a 
masterful manner; brings his authorities in witness; and presents the matter in such 
attractive form that it appeals to the general practitioner as a good book to have near 
at hand. In forty chapters he traverses the whole subject and in every aspect of it, 
giving many very good photomicrographic plates; while especially good are the homoeo- 
pathic remedy indications." 

From The Hahnemaniliau Monthly. "It is a book presenting established facts which 
have been proven and developed by the author's own personal experience, which has 
been extensive. The treatment of each disease, medical and surgical, is fully considered, 
brief drug indications being given under each condition described. The closing chapter 
is devoted to a complete resume of the symptomatic and clinical indications of the drugs 
used in these diseases, and it will prove to be of great assistance to all practitioners of 
medicine. The general make-up of the work is a good specimen of the bookmakers 
art, the illustrations being exceptionally good." 

From The Medical Times. "As we turned over one page after another of this book we 
were fascinated with the clear, terse style of the author, his wonderful faculty of con- 
densation, and the evidence of logical thought and extensive reading everywhere shown. 
We know of no work on the subjects discussed which contains so much valuabe in- 
formation in so short a space. We congratulate the author upon the excellence of his 
work, and the young publishing house upon the success of their new venture. 

HINTS AND SUGGESTIONS AS AIDS IN THE CARE AND 
PRESERVATION OF THE TEETH, AND THE RELATION OF 
THE DENTAL ORGANS TO OUR HEALTH. By Charles G. 
Pease, M. D., D. D. S. Professor of Oral Surgery in the Metropolitan Post 
Graduate School of Medicine of New York City, and Late Lecturer on 
Materia Medica, Therapeutics and Pathology in the New York Dental 
School, etc., etc. 98 pages. Cloth, $1.00 net; mailed, postpaid, on receipt 
of price. — Dr. Pease has given us a book of great value to every one, not 
alone to the medical profession. 

THE TREATMENT OF DISEASE WITH THE TWELVE 
TISSUE REMEDIES, BEING A TREATISE ON BIOCHEMISTRY. 
By William Boericke, M. D. 189 pages. $0.75 net; by mail $0.81. 
— This little book is a condensation of our larger works upon the subject, 
and gives all the sharp, characteristic symptoms of each of the 12 remedies, 
and is just the work for beginning the use of the Tissue Remedies in treat- 
ment of disease. 

NERVOUS DISEASES, AND HOMOEOPATHIC TREATMENT. 
By Joseph T. O'Connor, M. D., Ph. D. Professor of Nervous Diseases in 



MEDICAL BOOKS. 

the New York Homoeopathic Medical College and Hospital; Professor of 
Mental and Nervous Diseases in the New York Medical College and Hospital. 
Neurologist to the Laura Franklin Hospital for Children ; Consulting Neurol- 
ogist to the New York Ophthalmic Hospital; Neurologist to the Metropolitan 
Hospital BlackwelFs Island, New York. Member American Institute. Il- 
lustrated. 416 pages. Cloth, $3.75 net; by mail $3.99. Half morocco, 
$4.75 net; by mail $5.00. 

This work is based upon the author's lectures at the Colleges in which 
he is Professor of his specialty, and he has treated the subject comprehensively, 
yet without omission of necessary detail. The work is divided into sections, 
each considering some large division of the Nervous System and introduced 
by description of the finer anatomy assisted by illustrations. The dominant 
note of the book is Homoeopathy as given by Hahnemann's Organon. 




